What is the assessment and treatment plan for migraine?

Assessment and Plan for Migraine

The most effective approach to migraine management involves a stepped care strategy starting with NSAIDs for mild to moderate attacks, progressing to triptans for moderate to severe attacks, and implementing preventive therapy for patients adversely affected on ≥2 days per month despite optimized acute treatment. 1, 2

Assessment

• Migraine is characterized by recurrent episodes of headache, typically unilateral, pulsatile, moderate to severe intensity, aggravated by physical activity and associated with nausea, vomiting, photophobia, and phonophobia 3, 4
• Rule out secondary causes of headache through detailed history and physical examination, especially in patients with red flags such as sudden onset, fever, neck stiffness, or focal neurological deficits 3, 4
• Be particularly vigilant in patients with apparent late-onset migraine (after age 50), as this should raise suspicion of an underlying cause 1
• Monitor for medication overuse headache in patients using acute medications frequently (≥10 days/month for triptans or ≥15 days/month for NSAIDs) 1, 3

Acute Treatment Plan

1. First-line: NSAIDs 1, 3, 2

   • Use acetylsalicylic acid, ibuprofen, or diclofenac potassium for mild to moderate attacks
   • Administer early in the headache phase for maximum effectiveness
   • Paracetamol (acetaminophen) should only be used in patients intolerant to NSAIDs due to lower efficacy

2. Second-line: Triptans 1, 3, 2

   • Offer when NSAIDs provide inadequate relief
   • Most effective when taken early while headache is still mild
   • If one triptan is ineffective, try another as response varies between patients
   • Consider combining with NSAIDs to prevent relapse

3. Third-line options: 1, 3

   • Ditans (lasmiditan) or gepants (rimegepant, ubrogepant) for patients who fail triptans
   • Subcutaneous sumatriptan injection for patients with rapid-onset attacks or vomiting

4. Adjunct medications: 1, 3

   • Prokinetic antiemetics (domperidone, metoclopramide) for nausea/vomiting

5. Medications to avoid: 1, 3

   • Oral ergot alkaloids (poorly effective, potentially toxic)
   • Opioids and barbiturates (questionable efficacy, significant adverse effects, dependency risk)

Preventive Treatment Plan

Indications for preventive therapy: 1, 3, 2

• Patients adversely affected on ≥2 days per month despite optimized acute treatment
• Overuse of acute medication
• Attacks causing significant disability

Preventive medication options:

1. First-line options: 1, 3, 2

   • Beta-blockers (atenolol, bisoprolol, metoprolol, propranolol)
   • Topiramate (particularly beneficial for patients with obesity due to weight loss effect)
   • Candesartan

2. Second-line options: 1, 3

   • Flunarizine
   • Amitriptyline (particularly beneficial for patients with depression or sleep disorders)
   • Sodium valproate (in men only, contraindicated in women of childbearing potential)

3. Third-line options: 1, 3, 5

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

4. Evaluation timeline: 1, 3

   • Assess efficacy of oral preventives after 2-3 months
   • Assess CGRP monoclonal antibodies after 3-6 months
   • Assess onabotulinumtoxinA after 6-9 months
   • Consider pausing preventive treatment after 6-12 months of success to determine if still needed

Special Populations

1. Older patients: 1

   • Be vigilant for secondary headache disorders, which increase in incidence with age
   • Consider comorbidities and potential drug interactions
   • Monitor blood pressure in patients using triptans

2. Children and adolescents: 1

   • Bed rest alone may suffice for some attacks
   • Use ibuprofen as first-line medication at appropriate weight-based dosing
   • For prevention, consider propranolol, amitriptyline, or topiramate

3. Women with menstrual migraine: 1

   • Consider short-term prevention with NSAIDs or triptans for 5 days beginning 2 days before expected menstruation
   • Combined hormonal contraceptives may benefit women with pure menstrual migraine without aura
   • Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk

Management of Complications and Comorbidities

• Educate patients about medication overuse headache risk with frequent use of acute medications 1
• For established medication overuse headache, withdraw the overused medication (abrupt withdrawal preferred except for opioids) 1
• Identify and manage comorbid conditions including anxiety, depression, sleep disorders, and obesity 1, 3
• Adjust treatments considering potential interactions between medication side effects and patient comorbidities 1

Follow-up Plan

• Evaluate treatment response 2-3 months after initiation or change in treatment, then every 6-12 months 1
• Use headache calendars to track attack frequency, severity, and medication use 1, 4
• Assess effectiveness using attack frequency, attack severity, and migraine-related disability 1
• If treatment fails, review diagnosis, treatment strategy, dosing, and adherence 1
• Refer to specialist care for diagnostically challenging cases, difficult-to-treat cases, or those with significant comorbidities 1