What is the management approach for migraine without aura?

Management Approach for Migraine Without Aura

The optimal management of migraine without aura requires a stepped approach, starting with NSAIDs for mild to moderate attacks, progressing to triptans for moderate to severe attacks, and implementing preventive therapy for patients experiencing ≥2 migraine days per month with significant disability. 1, 2

Acute Treatment

First-Line Options

• NSAIDs are recommended as first-line treatment for mild to moderate migraine attacks 1, 2
  • Ibuprofen 400-800 mg every 6 hours 1
  • Diclofenac potassium for mild attacks 1
  • Acetylsalicylic acid (aspirin) 2
• Administer medication early in the headache phase for maximum effectiveness 2
• Acetaminophen alone has limited efficacy and should only be used in patients intolerant to NSAIDs 1

Second-Line Options

• Triptans (e.g., sumatriptan) are recommended for moderate to severe attacks or when NSAIDs fail 1, 2
• Sumatriptan is FDA-approved for acute treatment of migraine with or without aura in adults 3
  • Available doses: 25 mg, 50 mg, or 100 mg tablets 3
  • Maximum dose in a 24-hour period: 200 mg 3
  • A second dose should only be considered if some response to the first dose was observed, separated by at least 2 hours 3
• Consider combining triptans with NSAIDs to prevent relapse 2

Rescue Medication

• Self-administered rescue medications (e.g., opioids, butalbital-containing compounds) can be used when other treatments fail 4
• These medications may not completely eliminate pain but can help patients avoid emergency department visits 4

Preventive Treatment

Indications for Prevention

• Two or more attacks per month that produce disability lasting 3 or more days per month 4
• Contraindication to, or failure of, acute treatments 4
• Use of abortive medication more than twice per week 4
• Presence of uncommon migraine conditions (e.g., hemiplegic migraine) 4

First-Line Preventive Options

• Beta-blockers are recommended as first-line preventive treatment 1, 2
  • Propranolol (80-240 mg/day) has consistent evidence of efficacy 4
  • Timolol (20-30 mg/day) is also effective 4
  • Other options include atenolol, bisoprolol, and metoprolol 1, 2
• Topiramate (50-100 mg daily) is another first-line option 1, 2
• Amitriptyline is particularly beneficial for patients with comorbid depression or sleep disturbances 4

Third-Line Preventive Options

• OnabotulinumtoxinA is effective for chronic migraine 4, 1, 2
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) are effective for patients in whom at least two other preventive medications have failed 4, 1, 2

Management Strategies

Step Care vs. Stratified Care

• Step care: Start with safe, effective, inexpensive medications for acute attacks of any severity; if initial agent fails, use a second-line, more expensive, migraine-specific medication 4
• Stratified care: Initially stratify migraine attacks by severity, using migraine-specific agents for moderate to severe attacks regardless of previous response 4

Treatment Evaluation

• Evaluate treatment response within 2-3 months of initiation or change 1, 2
• Use headache calendars to track attack frequency, severity, and medication use 1, 2

Important Considerations and Pitfalls

Medication Overuse Headache

• Avoid overuse of acute medications, which can lead to medication-overuse headache 1, 2
• Limit use of triptans to <10 days/month and NSAIDs to <15 days/month 2
• Medications commonly associated with rebound headache include ergotamine, opiates, triptans, and analgesics containing butalbital, caffeine, or isometheptene 4

Comorbidity Management

• Identify and manage comorbid conditions including anxiety, depression, sleep disorders, and obesity 4, 2
• Adjust treatments considering potential interactions between medication side effects and patient comorbidities 2
• For patients with obesity, topiramate may be preferred due to its association with weight loss 4

Special Populations

• In women with menstrual migraine, consider short-term prevention with NSAIDs or triptans 2
• Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk 1
• Valproate sodium is absolutely contraindicated in women of childbearing age 1

Contraindications to Triptans

• History of coronary artery disease or coronary artery vasospasm 3
• Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders 3
• History of stroke, transient ischemic attack, or hemiplegic or basilar migraine 3
• Peripheral vascular disease or ischemic bowel disease 3
• Uncontrolled hypertension 3