What are the conservative treatment options for migraines?

Conservative Treatment Options for Migraines

Conservative treatment of migraines should focus on lifestyle modifications, non-pharmacological approaches, and appropriate use of acute and preventive medications to reduce frequency, severity, and disability associated with migraine attacks. 1, 2

Lifestyle Modifications and Trigger Management

• Identify and avoid personal migraine triggers through detailed headache diaries 1, 2
• Maintain regular sleep schedules with adequate sleep duration 1, 2
• Follow regular meal times to prevent hypoglycemia 1
• Ensure adequate hydration throughout the day 2
• Implement stress management techniques such as relaxation training 1, 2
• Avoid medication overuse (use of acute medications ≥10 days/month) which can lead to medication overuse headache 1, 3

Acute Pharmacological Treatment

First-Line Options

• NSAIDs: Ibuprofen is recommended as first-line treatment for mild to moderate migraines in both children and adults 4, 2, 5
• Other effective NSAIDs include naproxen, diclofenac potassium, and aspirin 1, 6
• Acetaminophen/paracetamol may be used in patients who cannot tolerate NSAIDs, though it has lower efficacy 1, 6

Second-Line Options

• Triptans (sumatriptan, rizatriptan, zolmitriptan, almotriptan) are recommended for moderate to severe migraines or when NSAIDs fail 4, 3
• Take triptans early in the migraine attack when pain is still mild for best results 4, 3
• If one triptan is ineffective, try another or a NSAID-triptan combination 4, 7
• Non-oral triptans (nasal sprays, injections) should be considered for rapidly escalating pain or significant nausea/vomiting 4, 3

Important Triptan Considerations

• Maximum daily dose of sumatriptan is 200mg in a 24-hour period 3
• Wait at least 2 hours between doses of triptans 3
• Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, and history of stroke or TIA 3
• Monitor for serotonin syndrome when combining triptans with SSRIs, SNRIs, or TCAs 3

Additional Acute Options

• Antiemetics (metoclopramida, domperidona) can be added to treat nausea and vomiting 4, 1
• Newer options like gepants (ubrogepant, rimegepant) or ditans (lasmiditan) may be useful when triptans fail or are contraindicated 1, 8
• Avoid opioids and barbiturates due to limited efficacy, significant adverse effects, and risk of dependence 1, 5

Preventive Treatment

Indications for Prevention

• Consider preventive treatments in patients with frequent (typically >4 attacks/month) or disabling headaches 4, 2
• Preventive treatment is also indicated in cases of medication overuse headache 4, 1

Pharmacological Prevention Options

• Topiramato is recommended as a first-line preventive option due to efficacy and lower cost 1, 2
• Propranolol has good evidence for migraine prevention 4, 2
• Amitriptyline may be beneficial, particularly when combined with cognitive behavioral therapy 4, 2
• OnabotulinumtoxinA is specifically approved for chronic migraine 1
• Anti-CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) are effective in patients who have failed at least two previous preventive medications 1

Duration of Preventive Treatment

• The recommended duration for preventive treatment is 6-12 months before considering discontinuation 1

Non-Pharmacological Prevention

• Cognitive behavioral therapy shows good evidence, especially when combined with medication 2
• Relaxation techniques and biofeedback may be beneficial 2, 8
• Neuromodulation techniques including single-pulse transcranial magnetic stimulation, external trigeminal nerve stimulation, remote electrical neuromodulation, and non-invasive vagus nerve stimulation show promise 8
• Certain supplements have evidence for migraine prevention (in decreasing order of preference): magnesium, Petasites hybridus (butterbur), feverfew, coenzyme Q10, riboflavin, and alpha lipoic acid 9

Pitfalls and Caveats

• Avoid medication overuse, which can transform episodic migraine to chronic migraine 1, 3
• Early treatment of acute attacks is crucial for optimal efficacy 4, 7
• Be aware of potential cardiovascular risks with triptans in patients with risk factors 3
• Consider comorbidities when selecting preventive treatments (e.g., topiramato for patients with obesity, amitriptyline for those with depression or sleep disorders) 1
• Monitor for and address common comorbidities such as anxiety, depression, and sleep disorders 1