What is the recommended management for migraines in an adult male?

Migraine Management in Adult Males

For adult males with migraine, the recommended management includes NSAIDs as first-line treatment for mild to moderate attacks, with triptans added for moderate to severe attacks or when NSAIDs are ineffective, along with preventive therapy when attacks are frequent or disabling. 1

Acute Treatment Algorithm

First-Line Treatment (Mild to Moderate Attacks)

• NSAIDs are the first-line treatment for most patients with mild to moderate migraine attacks 1
  • Recommended options include:
    • Aspirin (650-1,000 mg every 4-6 hours, max 4g/day) 1
    • Ibuprofen (400-800 mg every 6 hours, max 2.4g/day) 1
    • Naproxen sodium (275-550 mg every 2-6 hours, max 1.5g/day) 1
    • Combination analgesics containing caffeine (e.g., aspirin + acetaminophen + caffeine) 1

Second-Line Treatment (Moderate to Severe Attacks)

• Add a triptan when NSAIDs provide inadequate relief or for moderate to severe attacks 1
  • Triptans (serotonin 5-HT1B/1D agonists) with proven efficacy include:
    • Sumatriptan (25-100 mg orally, max 200 mg/day) 2
    • Rizatriptan, zolmitriptan, or naratriptan 1
  • Take triptans early in an attack when pain is still mild for best efficacy 1
  • Contraindications include coronary artery disease, uncontrolled hypertension, and hemiplegic migraine 2

For Attacks with Significant Nausea/Vomiting

• Use non-oral routes of administration 1
• Add antiemetics like metoclopramide (10 mg) to treat nausea and improve gastric motility 1

Rescue Medication

• For severe attacks unresponsive to above treatments, consider self-administered rescue medication 1
• Limit and carefully monitor use of opioids and butalbital-containing analgesics due to risk of dependency and medication overuse headache 1

Preventive Treatment

Indications for Preventive Therapy

• Two or more migraine attacks per month with disability for 3+ days/month 1
• Use of rescue medication more than twice weekly 1
• Failure of or contraindications to acute treatments 1
• Presence of uncommon migraine conditions (e.g., hemiplegic migraine) 1

Preventive Medication Options

• First-line preventive medications with documented efficacy include:
  • Beta-blockers (particularly beneficial for patients with hypertension) 1, 3
  • Topiramate (first choice for chronic migraine and patients with obesity) 1
  • Amitriptyline (beneficial for patients with comorbid depression or sleep disturbances) 1, 3
  • Divalproex sodium 3
• For chronic migraine (≥15 headache days/month):
  • Topiramate is first-line due to lower cost 1
  • OnabotulinumtoxinA and CGRP monoclonal antibodies for those who fail other preventives 1

Non-Pharmacological Approaches

Trigger Identification and Management

• Encourage use of a headache diary to identify and avoid personal triggers 1
• Common triggers include alcohol, caffeine, certain foods, stress, irregular sleep, and environmental factors 1, 4

Lifestyle Modifications

• Maintain regular sleep, eating, and work habits 4, 5
• Regular exercise (40 minutes three times weekly) can be as effective as some preventive medications 1, 5
• Weight management for patients with obesity 1, 5

Behavioral Treatments

• Offer behavioral treatments to all patients 1
• Evidence-based options include:
  • Relaxation training and meditative therapy 1, 6
  • Biofeedback 1, 6
  • Cognitive behavioral therapy 1, 6

Important Considerations and Pitfalls

• Medication Overuse Headache: Limit acute medications to no more than 2-3 days per week to prevent medication overuse headache 1
• Comorbidities: Assess for and manage common comorbidities like anxiety, depression, and sleep disorders 1
• Rebound Headaches: Be vigilant for rebound headaches from withdrawal of analgesics, triptans, ergotamine, or caffeine-containing medications 1
• Patient Education: Explain that migraine is a neurological disorder with biological basis and associated functional changes in the nervous system 1
• Realistic Expectations: Set realistic expectations as complete resolution of symptoms may not be achievable for all patients 1