What are the treatment protocols, causes, and prophylaxis (preventive measures) for migraines?

Treatment Protocol, Causes, and Prophylaxis of Migraine

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy for acute attacks, while preventive therapy should be considered for patients with two or more attacks per month causing significant disability. 1

Causes of Migraine

• Migraine is considered a disorder of the pain modulating system, caused by disruptions of normal neural networks of the head, resulting in meningeal vasodilation and inflammation perceived as head pain 2
• Common triggers include alcohol, caffeine, foods containing tyramine or nitrates, stress, fatigue, perfumes, fumes, glare, and flickering lights 1
• Hormonal fluctuations, particularly in women, can trigger migraine attacks 3
• Genetic factors play a significant role in migraine susceptibility 2

Acute Treatment Protocol

First-Line Treatment

• NSAIDs are recommended as first-line treatment for mild to moderate migraine attacks 1
• Most consistent evidence exists for aspirin, ibuprofen, naproxen sodium, and the acetaminophen-aspirin-caffeine combination 1
• Acetaminophen alone is ineffective for migraine 1

Second-Line Treatment

• Migraine-specific agents (triptans, dihydroergotamine [DHE]) should be used in patients whose migraine attacks do not respond to NSAIDs 1
• Effective triptans include oral naratriptan, rizatriptan, zolmitriptan, and oral/subcutaneous sumatriptan 1
• Important safety consideration: Triptans are contraindicated in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or those at risk for heart disease 1, 4

Special Considerations

• Select a non-oral route of administration when nausea or vomiting are significant components of the attack 1
• Treat nausea with an antiemetic drug 1
• Avoid opioids except when other medications cannot be used, risk of abuse has been addressed, and sedation is not a concern 1
• Be vigilant for medication overuse headache, which can occur with frequent use (>10 days/month) of acute migraine medications 4

Migraine Prevention (Prophylaxis)

Indications for Preventive Therapy

• Two or more migraine attacks per month with disability lasting 3 or more days per month 1, 3
• Use of rescue medication more than twice per week 1, 3
• Failure of or contraindications to acute treatments 1
• Presence of uncommon migraine conditions (e.g., prolonged aura, migrainous infarction, hemiplegic migraine) 1

First-Line Preventive Medications

• Strong recommendations from the 2023 VA/DoD guidelines include: 1

  • Candesartan or telmisartan for episodic migraine
  • Erenumab, fremanezumab, or galcanezumab for episodic or chronic migraine

• Other effective preventive medications include: 1

  • Beta blockers: propranolol (80-240 mg/day), timolol (20-30 mg/day)
  • Tricyclic antidepressants: amitriptyline (30-150 mg/day)
  • Anticonvulsants: divalproex sodium (500-1,500 mg/day), sodium valproate (800-1,500 mg/day), topiramate
  • Angiotensin-converting enzyme inhibitors: lisinopril
  • Supplements: oral magnesium

Implementation of Preventive Therapy

• Start with a low dose and titrate slowly upward until clinical benefits are achieved or side effects limit further increases 1, 3
• Allow an adequate trial period of 2-3 months before determining efficacy 1, 3
• Monitor for medication overuse, which can interfere with prophylactic treatment 3
• Use headache diaries to track attack frequency, severity, duration, resulting disability, response to treatment, and adverse effects 3

Special Considerations and Pitfalls

• Medication overuse headache: Limit use of acute treatments to no more than twice a week to prevent rebound headaches 1
• Contraindications to triptans: Avoid in patients with Wolff-Parkinson-White syndrome, cardiac accessory conduction pathway disorders, coronary artery disease, Prinzmetal's variant angina, history of stroke or TIA, or uncontrolled hypertension 4
• Serotonin syndrome risk: Be cautious when combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors 4
• OnabotulinumtoxinA: Recommended for prevention of chronic migraine (not episodic) but carries risks including problems with swallowing, speaking, or breathing 1, 5
• Pregnancy considerations: Many migraine medications are contraindicated during pregnancy; treatment must be adjusted accordingly 6

Monitoring and Follow-up

• Track progress with daily headache diaries to assess treatment effectiveness 1, 3
• After a period of stability with preventive treatment, consider tapering or discontinuing medication 1
• Educate patients about migraine as a disease and principles of management 3
• Encourage identification of personal triggers to avoid future attacks 1