What is the treatment for a complex migraine?

Treatment of Complex Migraine

For complex migraine, treatment should follow a stepped care approach starting with NSAIDs as first-line therapy, progressing to triptans as second-line, and considering newer agents like ditans or gepants as third-line options, with careful attention to avoiding medications that may increase stroke risk. 1

Understanding Complex Migraine

Complex migraine typically refers to migraine with aura or migraine with neurological symptoms that may mimic stroke. Key considerations include:

• Complex migraine with aura carries an increased risk of ischemic stroke, especially in younger patients 2, 3
• Migrainous infarction is a rare but serious complication where aura symptoms persist beyond 60 minutes with evidence of infarction 2
• Treatment must balance effective pain relief with minimizing stroke risk 4

Acute Treatment Algorithm

First-Line Treatment (Mild to Moderate Attacks)

• NSAIDs are recommended as initial therapy 1
  • Ibuprofen 400-800 mg every 6 hours (maximum 2.4g/day) 1
  • Naproxen sodium 275-550 mg every 2-6 hours (maximum 1.5g/day) 1
  • Aspirin 650-1000 mg every 4-6 hours (maximum 4g/day) 1
• Combination analgesics containing caffeine may also be effective 1

Second-Line Treatment (Moderate to Severe Attacks)

• Triptans are recommended when NSAIDs provide inadequate relief 1
  • Most effective when taken early in an attack while pain is still mild 1
  • Sumatriptan is commonly used and works by binding to 5-HT1B/1D receptors 5
  • If one triptan fails, others may still provide relief 1
  • For patients with vomiting or rapid onset, consider non-oral routes (subcutaneous sumatriptan) 1

Third-Line Treatment

• For patients who fail triptan therapy or have contraindications:
  • Ditans (lasmiditan) or gepants (ubrogepant, rimegepant) may be considered 1
  • Note that lasmiditan causes temporary driving impairment 1

Adjunctive Therapy

• For nausea/vomiting:
  • Metoclopramide (Reglan) or prochlorperazine (Compazine) 1
  • Domperidone can be used as an oral antiemetic 1
• For mild attacks:
  • Isometheptene combinations (with acetaminophen and dichloralphenazone) 1

Important Cautions for Complex Migraine

• Avoid ergot alkaloids (ergotamine) due to vasoconstrictive properties that may increase stroke risk in patients with complex migraine 2, 4, 6
• Use triptans with caution in patients with risk factors for cardiovascular disease 1
• Avoid opioids and barbiturates due to:
  • Risk of medication overuse headache 1
  • Dependency and eventual loss of efficacy 1
  • Limited evidence supporting their use 1

Preventive Treatment

For patients with frequent complex migraines (≥2 attacks/month causing ≥3 days of disability):

• First-line preventive options:

  • Beta-blockers like propranolol are FDA-approved for migraine prevention 7
  • Topiramate (100-200 mg daily) 1, 4
  • Valproic acid (500-1000 mg daily) 4

• For chronic migraine (≥15 headache days/month):

  • Topiramate is first-line due to lower cost 1
  • OnabotulinumtoxinA may be considered after other preventives fail 1
  • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) for patients who have failed at least two other preventive medications 1

Managing Comorbidities

• Identify and treat comorbid conditions that may affect treatment choices:
  • Depression or sleep disturbances: Consider amitriptyline 1
  • Obesity: Consider topiramate (associated with weight loss) 1
  • Cardiovascular risk factors: Modify lifestyle factors and avoid vasoconstrictors 3

Monitoring and Follow-up

• Educate patients about medication overuse headache risk with frequent use of acute medications 1
• Limit acute treatment to no more than twice weekly to prevent medication overuse headache 1
• Monitor for transformation to chronic migraine, especially in patients with risk factors (female sex, high headache frequency, inadequate treatment) 1

Remember that complex migraine treatment requires balancing effective pain control with minimizing the risk of serious complications like stroke. Early intervention with appropriate medications and preventive strategies can significantly improve outcomes and quality of life 1, 6.