What are the treatment options for episodic vs chronic migraine?

Treatment Options for Episodic vs Chronic Migraine

For acute treatment of migraine, combination therapy of a triptan with an NSAID or acetaminophen is recommended as first-line treatment for moderate to severe episodic migraine, while chronic migraine requires preventive therapy in addition to acute treatment strategies. 1

Definitions and Classification

• Episodic migraine is defined as headaches occurring on fewer than 15 days per month 2
• Chronic migraine is defined as headaches occurring on at least 15 days per month for at least 3 months, with migraine features on at least 8 days per month 2
• Patients can progress from episodic to chronic migraine over time, with medication overuse being a significant risk factor 3

Acute Treatment Options for Episodic Migraine

First-Line Treatment

• For mild episodic migraine: NSAIDs (aspirin, celecoxib, diclofenac, ibuprofen, naproxen) or acetaminophen monotherapy 1
• For moderate to severe episodic migraine: Combination therapy of a triptan (sumatriptan, rizatriptan, etc.) with an NSAID or acetaminophen 1
• Treatment should begin as soon as possible after headache onset to maximize efficacy 1

Second-Line Treatment

• For patients who don't respond to or cannot tolerate first-line treatments, consider CGRP antagonists-gepants (rimegepant, ubrogepant, zavegepant) 1, 4
• Dihydroergotamine (DHE) can be considered for patients with inadequate response to first-line treatments 1, 4
• Lasmiditan (ditan) should be reserved for patients who don't tolerate or have inadequate response to all other pharmacologic treatments 1, 4

Important Cautions

• Opioids and butalbital-containing medications should not be used for migraine treatment 1, 5
• Be aware of medication overuse headache risk (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
• For patients with severe nausea or vomiting, consider non-oral formulations (such as intranasal triptans) and add an antiemetic 1, 4

Treatment for Chronic Migraine

Preventive Treatment

• Preventive therapy is required for all patients with chronic migraine 2, 3
• First-line preventive options include beta-blockers (metoprolol, propranolol), antiseizure medication valproate, SNRIs (venlafaxine), or TCAs (amitriptyline) 1
• CGRP antagonists-gepants (atogepant, rimegepant) or CGRP monoclonal antibodies (eptinezumab, erenumab, fremanezumab, galcanezumab) are effective preventive options 1
• Consider ACE inhibitors (lisinopril), ARBs (candesartan, telmisartan), or SSRIs (fluoxetine) if first-line treatments are not tolerated or ineffective 1

Acute Treatment

• Patients with chronic migraine still require acute treatment for breakthrough headaches, following the same principles as for episodic migraine 1
• Be particularly vigilant about medication overuse, which can worsen chronic migraine 1, 3

Treatment Algorithm for Both Types

1. For mild attacks: Start with NSAIDs or acetaminophen 1
2. For moderate to severe attacks: Use combination therapy of a triptan with an NSAID or acetaminophen 1
3. For inadequate response: Consider CGRP antagonists-gepants or dihydroergotamine 1, 4
4. As last resort: Try lasmiditan for patients who don't respond to other treatments 1, 4
5. For chronic migraine: Add preventive therapy while managing acute attacks 1, 3

Lifestyle Modifications for Both Types

• Stay well hydrated and maintain regular meals 1, 5
• Ensure sufficient and consistent sleep patterns 1
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1
• Manage stress with relaxation techniques or mindfulness practices 1, 4
• Pursue weight loss if overweight or obese 1
• Identify and avoid personal migraine triggers 1, 5

Special Considerations

• In women of childbearing potential and those who are pregnant or breastfeeding, discuss the adverse effects of treatments during pregnancy and lactation 1, 4
• Consider using a headache diary to track frequency, severity, triggers, and treatment response 1
• If episodic migraine occurs frequently or treatment doesn't provide adequate response, consider adding preventive medications 1
• Preventive treatment should be initiated at a low dose and gradually increased until desired outcomes are achieved 1