What are the guidelines for managing migraine?

Guidelines for Migraine Management

NSAIDs are the first-line treatment for most patients with migraine, followed by triptans for those who don't respond to NSAIDs, with preventive therapy indicated for patients experiencing frequent or disabling attacks. 1, 2

Acute Treatment of Migraine

First-Line Treatment

• NSAIDs are first-line treatment for mild to moderate migraine attacks, with consistent evidence supporting aspirin, ibuprofen, naproxen sodium, and the acetaminophen-aspirin-caffeine combination 1, 2
• Acetaminophen alone is ineffective for migraine treatment 1
• Treatment should be taken early in the migraine attack for maximum effectiveness 3

Second-Line Treatment

• Triptans (serotonin 5-HT1B/1D agonists) should be used when NSAIDs are ineffective 1, 2
• Effective triptans include sumatriptan, rizatriptan, zolmitriptan, naratriptan, almotriptan, frovatriptan, and eletriptan 4, 5
• Triptans are contraindicated in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or risk factors for heart disease 1, 6

Administration Considerations

• Non-oral routes of administration (nasal sprays, injections) should be used when nausea or vomiting are significant components of attacks 1, 2
• Antiemetic medications should be added when nausea is present 1
• Combination therapy of a triptan with an NSAID may be more effective than either medication alone for patients with insufficient relief 2

Medication Overuse Prevention

• Limit acute treatments to no more than twice a week to prevent medication-overuse headaches 1, 2
• Rebound headaches can occur with frequent use of opiates, triptans, ergotamine, and analgesics containing caffeine, isometheptene, or butalbital 1

Preventive Treatment

Indications for Preventive Therapy

• Preventive treatment should be considered for patients with:
  • Two or more migraine attacks per month with disability lasting 3+ days per month 1, 7
  • Use of rescue medication more than twice per week 1, 7
  • Failure of or contraindications to acute treatments 1, 7
  • Uncommon migraine conditions (e.g., prolonged aura, migrainous infarction, hemiplegic migraine) 1

First-Line Preventive Medications

• Beta blockers: propranolol (80-240 mg/day) and timolol (20-30 mg/day) have good evidence for efficacy 1, 7
• Tricyclic antidepressants: amitriptyline (30-150 mg/day) is effective for migraine prevention 1, 7
• Anticonvulsants: divalproex sodium (500-1500 mg/day) and sodium valproate (800-1500 mg/day) are effective preventive options 1, 7
• OnabotulinumtoxinA injections are approved for prevention of chronic migraine (15+ headache days per month) 8, 9

Implementation of Preventive Therapy

• Start with a low dose and titrate slowly upward until clinical benefits are achieved or side effects limit increases 7
• Allow an adequate trial period of 2-3 months before determining efficacy 7
• Use headache diaries to track attack frequency, severity, duration, disability, treatment response, and adverse effects 7

Special Considerations

Rescue Medications

• Consider rescue medications (e.g., antiemetics, corticosteroids) when standard treatments fail 4
• Opioids should be considered only if other medications cannot be used, after addressing risk of abuse and sedation concerns 1

Medication Overuse Headache

• Medication overuse headache can occur with frequent use of acute medications (≥15 days/month with most medications; ≥10 days/month with triptans) 2, 7
• Detoxification may be necessary for patients with medication overuse headache 2

Trigger Identification

• Patients should be encouraged to identify and avoid migraine triggers (e.g., alcohol, caffeine, foods containing tyramine or nitrates, stress, fatigue, perfumes, fumes, glare, flickering lights) 1

By following these guidelines and individualizing treatment based on attack severity, frequency, and patient-specific factors, most migraine patients can achieve significant improvement in symptoms and quality of life.