What are the recommended management strategies for migraine?

Management of Migraine

Start with NSAIDs (aspirin, ibuprofen, naproxen, or diclofenac) for mild-to-moderate attacks, escalate to triptans for moderate-to-severe attacks or when NSAIDs fail, and use a stratified care approach based on attack severity rather than stepping through treatments sequentially. 1

Acute Treatment Algorithm

First-Line Treatment: NSAIDs

• Acetylsalicylic acid (aspirin), ibuprofen, and diclofenac potassium have the strongest evidence as first-line medications for mild-to-moderate migraine. 1
• Typical dosing: aspirin 900-1000mg, ibuprofen 400-800mg every 6-8 hours 2
• Paracetamol (acetaminophen) has less efficacy and should only be used in patients intolerant of NSAIDs 1
• Take medication early in the attack when headache is still mild for maximum effectiveness. 1

Second-Line Treatment: Triptans

• All triptans have well-documented effectiveness for moderate-to-severe migraine, with sumatriptan, rizatriptan, naratriptan, and zolmitriptan having the strongest evidence. 1, 3, 2
• Triptans are most effective when taken early in an attack while headache is still mild, but should NOT be used during the aura phase 1
• If one triptan is ineffective, try a different triptan as individual response varies. 1
• Subcutaneous sumatriptan 6mg provides the highest efficacy (59% complete pain relief at 2 hours) and is useful when patients rapidly reach peak intensity or cannot take oral medications due to vomiting 1, 3
• Standard oral sumatriptan dosing: 25-100mg, with maximum 200mg per 24 hours; separate doses by at least 2 hours 4

Route Selection Based on Symptoms

• For significant nausea or vomiting, use non-oral routes: subcutaneous, intranasal, or rectal formulations. 3, 5, 2
• Intranasal sumatriptan 5-20mg is effective when nausea/vomiting is prominent 3
• Oral medications have delayed absorption due to gastroparesis during migraine attacks 2

Adjunct Antiemetic Therapy

• Add metoclopramide 10mg or prochlorperazine 10mg for nausea, as these also provide synergistic analgesia. 3, 5
• Metoclopramide improves gastric motility which is impaired during attacks 5, 2
• Use antiemetics even when nausea is present without vomiting, as nausea is one of the most disabling migraine symptoms 2

Third-Line and Refractory Treatment

• Intranasal or intravenous dihydroergotamine (DHE) 0.5-1.0mg has good evidence for refractory migraine. 3, 5
• Combination therapy: triptan plus NSAID simultaneously for enhanced efficacy 1, 3
• For headache relapse (return of symptoms within 48 hours), patients can repeat triptan treatment or combine with fast-acting naproxen 1

Emergency Department/Urgent Care Protocol

IV Combination Therapy

• First-line IV combination: metoclopramide 10mg IV plus ketorolac 30mg IV provides rapid pain relief with minimal rebound risk. 3
• Ketorolac has rapid onset with approximately 6-hour duration 3
• Prochlorperazine 10mg IV is comparable to metoclopramide in efficacy 3

Important Cautions for IV Therapy

• Reduce ketorolac dose in patients ≥65 years or with renal impairment 3
• Use caution with ketorolac in patients with history of GI bleeding or heart disease 3
• Avoid opioids (including hydromorphone) as they lead to dependency, rebound headaches, and loss of efficacy. 3, 5

Critical Contraindications and Safety Considerations

Triptan Contraindications (FDA Label)

• Triptans are contraindicated in: coronary artery disease, Wolff-Parkinson-White syndrome, history of stroke/TIA, hemiplegic or basilar migraine, peripheral vascular disease, ischemic bowel disease, and uncontrolled hypertension. 4
• Do not use within 24 hours of another 5-HT1 agonist or ergotamine-containing medication 4
• Do not use within 2 weeks of MAO-A inhibitor 4
• Perform cardiac evaluation in patients with multiple cardiovascular risk factors before prescribing 4

Medication Overuse Headache Prevention

• Limit acute treatments to no more than twice weekly (2 days per week) to prevent medication overuse headache. 3, 5, 2
• Overuse of acute medications (≥10 days per month) leads to increasing headache frequency and potentially daily headaches 3, 4
• Detoxification may be necessary if medication overuse headache develops 4

Serotonin Syndrome Risk

• Monitor for serotonin syndrome when triptans are used with SSRIs, SNRIs, TCAs, or MAO inhibitors 4
• Symptoms include mental status changes, autonomic instability, neuromuscular aberrations, and GI symptoms 4
• Discontinue sumatriptan immediately if serotonin syndrome is suspected 4

Stratified Care vs. Step Care Approach

Use stratified care (selecting initial treatment based on attack severity) rather than step care (starting all patients on NSAIDs and escalating only after failure), as stratified care provides significantly better clinical outcomes. 6

• Stratified care achieves 52.7% headache response at 2 hours vs. 40.6% with step care across attacks 6
• Stratified care reduces disability time compared to step care strategies 6
• For mild-to-moderate attacks: start with NSAIDs 1
• For moderate-to-severe attacks: start directly with triptans 1, 2

Patient Education Essentials

• Explain migraine as a disease and principles of effective management, including correct medication use, potential adverse effects, and importance of avoiding medication overuse. 1
• Set realistic expectations: goal is to return control from disease to patient, reducing attack-related disability rather than complete cure 1
• Trigger factors are often overemphasized; true triggers are usually self-evident (exception: menstruation-related migraine) 1
• Distinguish between aggravating factors (worsen headache during attacks, like physical activity) and predisposing factors (increase susceptibility, like poor sleep) 1

Common Pitfalls to Avoid

• Do not use triptans during aura phase—wait until headache begins 1
• Do not routinely use opioids or barbiturate-containing compounds due to dependency risk and questionable efficacy 5, 7
• Do not use oral ergot alkaloids as routine therapy 5
• Avoid establishing patterns of frequent acute medication use (>2 days/week) 3, 5, 2
• Do not delay triptan use in patients with severe attacks—stratified approach is superior to stepping through NSAIDs first 6