What are the treatment options for intractable migraines?

Treatment Options for Intractable Migraines

For patients with intractable migraines, a stepped care approach using migraine-specific agents (triptans, dihydroergotamine) after failure of NSAIDs is recommended, with consideration of newer therapies like CGRP antagonists (gepants) or ditans for those who fail standard treatments. 1

First-Line Treatment Options

• NSAIDs are the first-line treatment for most migraine attacks, with the strongest evidence supporting acetylsalicylic acid, ibuprofen, and diclofenac potassium 1
• Combination analgesics containing caffeine (such as acetaminophen-aspirin-caffeine combinations) are effective first-line options 1
• Acetaminophen alone is ineffective and not recommended for migraine 1
• Antiemetics should be added when nausea or vomiting are significant symptoms 1

Second-Line Treatment Options

• Triptans (serotonin 5-HT1B/1D agonists) should be used when NSAIDs fail to provide adequate relief 1
• Evidence supports oral naratriptan, rizatriptan, zolmitriptan, and oral/subcutaneous sumatriptan 1
• Triptans are most effective when taken early in an attack while pain is still mild 1
• Triptans are contraindicated in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or cardiovascular disease 1, 2

Third-Line Treatment Options

• Ditans (lasmiditan, a 5-HT1F receptor agonist) or CGRP antagonists (gepants) may be considered when triptans fail or are contraindicated 1
• Dihydroergotamine (DHE) intranasal spray has good evidence for efficacy and safety 1
• Butorphanol nasal spray may be effective for severe attacks 1

Route of Administration Considerations

• Non-oral routes should be selected when significant nausea or vomiting is present 1
• Options include:
  • Subcutaneous sumatriptan for rapid relief 1
  • Intranasal triptans or DHE 1
  • Parenteral NSAIDs like ketorolac (Toradol) for severe attacks 1

Rescue Medications

• For severe migraines that don't respond to other treatments, rescue medications may be necessary 1
• Options include:
  • Dopamine antagonists (prochlorperazine, metoclopramide) 1
  • Parenteral steroids for status migrainosus (severe, continuous migraine lasting up to a week) 1
  • Opioids may be considered if other medications cannot be used, but risks of dependency and medication overuse headache must be addressed 1

Preventive Treatment

• Preventive treatment should be considered when:

  • Migraine attacks occur on ≥2 days per month with significant disability 1
  • Acute treatments are used more than twice weekly 1
  • Acute treatments fail or are contraindicated 1
  • Uncommon migraine conditions are present (e.g., hemiplegic migraine) 1

• First-line preventive options:

  • Beta blockers without intrinsic sympathomimetic activity (atenolol, bisoprolol, metoprolol, propranolol) 1
  • Topiramate 1
  • Candesartan 1

• Second-line preventive options:

  • Flunarizine 1
  • Amitriptyline 1
  • Sodium valproate (contraindicated in women of childbearing potential) 1

• Third-line preventive options:

  • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) 1
  • OnabotulinumtoxinA for chronic migraine 1

Medication Overuse Headache Prevention

• Limit acute treatment to no more than twice a week to prevent medication overuse headache 1
• Medication overuse headache can occur with:
  • NSAIDs used ≥15 days/month 1
  • Triptans, ergotamine, or opioids used ≥10 days/month 1, 2
  • Combination analgesics containing caffeine, isometheptene, or butalbital 1

Treatments to Avoid

• Opioids and butalbital-containing analgesics should not be used routinely 1
• Oral ergot alkaloids are poorly effective and potentially toxic 1
• Barbiturates have questionable efficacy and risk of dependency 1

Non-Pharmacological Options

• Neuromodulatory devices can be considered as adjuncts or alternatives when medications are contraindicated 1
• Biobehavioural therapy and acupuncture have some supporting evidence 1
• Lifestyle modifications may help reduce attack frequency:
  • Regular meals and hydration 1
  • Consistent sleep patterns 1
  • Regular physical activity 1
  • Stress management techniques 1

By following this stepped approach to treatment and considering both acute and preventive strategies, most patients with intractable migraines can achieve improved control of their condition and better quality of life.