What is the management plan for migraines with normal MRI and lab results ruling out secondary causes?

Management of Migraines with Normal MRI and Labs

Once secondary causes are excluded with normal MRI and labs, initiate a comprehensive treatment plan that includes optimized acute therapy, consideration for preventive treatment if headaches occur ≥2 days per month, identification and management of triggers and comorbidities, and patient education about medication overuse headache risk. 1

Initial Assessment and Diagnosis Confirmation

• Confirm the diagnosis meets migraine criteria after excluding secondary causes with neuroimaging and laboratory work 1
• Implement a headache diary to track frequency, severity, triggers, and medication use—this is essential for monitoring treatment response and identifying medication overuse 1
• Use validated tools like the Headache Impact Test-6 (HIT-6) and Migraine-Specific Quality-of-Life Questionnaire (MSQ) to assess disease burden 1
• Identify modifiable exacerbating factors including sleep disturbances, dietary triggers, stress, obesity, and hormonal changes 1, 2

Acute Treatment Algorithm

First-Line Acute Therapy

• Start with NSAIDs (aspirin, ibuprofen, or diclofenac potassium) plus a prokinetic antiemetic (domperidone or metoclopramide) if nausea/vomiting is present 1, 3, 4
• Paracetamol has lower efficacy and should only be used in patients intolerant to NSAIDs 1, 3
• Treat early in the attack when headache is still mild for maximum effectiveness 1, 3

Second-Line: Triptans

• If three consecutive attacks fail with NSAIDs, advance to triptans (sumatriptan, rizatriptan, zolmitriptan, eletriptan, almotriptan, naratriptan, or frovatriptan) 1, 3, 4
• Triptans are most effective when taken early while pain is still mild 1, 3, 5
• If one triptan is ineffective, try a different triptan as response varies between agents 1, 4
• For patients with rapid-onset severe pain or vomiting, subcutaneous sumatriptan may be most effective 4
• Critical caveat: Screen for cardiovascular risk factors before prescribing triptans; they are contraindicated in patients with ischemic heart disease, uncontrolled hypertension, or cerebrovascular disease 5, 6

Third-Line Options

• If all available triptans fail, consider ditans (lasmiditan) or gepants (ubrogepant, rimegepant) 1, 4
• Avoid ergot alkaloids, opioids, and barbiturates due to questionable efficacy, significant adverse effects, and dependency risk 7, 4

Medication Overuse Headache Prevention

• Limit acute medication use to no more than 2 days per week (or 10 days per month) to prevent medication overuse headache (MOH) 7, 3, 5
• Educate patients that overuse of any acute medication—including NSAIDs, triptans, and combination analgesics—can cause rebound headaches 3, 5

Preventive Treatment Indications and Algorithm

When to Initiate Prevention

• Consider preventive therapy when migraine adversely affects the patient ≥2 days per month despite optimized acute treatment 1, 7, 3
• Other indications include: medication overuse, contraindications to acute medications, patient preference, or special circumstances like hemiplegic migraine 7, 3

First-Line Preventive Medications

• Beta-blockers without intrinsic sympathomimetic activity (propranolol, metoprolol, atenolol, or bisoprolol) 1, 7
• Topiramate (gradually titrate to 100 mg/day; particularly beneficial in patients with obesity due to weight loss effect) 1, 3
• Candesartan 1

Second-Line Preventive Medications

• Flunarizine 1
• Amitriptyline (particularly useful in patients with comorbid depression or sleep disturbances) 1, 3
• Sodium valproate in men only (strictly contraindicated in women of childbearing potential) 1

Third-Line: Advanced Therapies

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) for patients who have failed at least two other preventive medications 1, 3
• OnabotulinumtoxinA (Botox) is FDA-approved specifically for chronic migraine (≥15 headache days per month, each lasting ≥4 hours); requires specialist administration with at least 2-3 treatment cycles before declaring non-response 3

Efficacy Assessment Timeline

• Evaluate oral preventive medications after 2-3 months of adequate dosing 3, 4
• Evaluate CGRP antibodies after 3-6 months 3
• Evaluate onabotulinumtoxinA after 6-9 months (2-3 treatment cycles) 3

Comorbidity Management

• Identify and treat comorbid conditions including depression, anxiety, sleep disorders, obesity, and chronic pain conditions—their management improves migraine outcomes 1, 3, 4
• For patients with depression or insomnia, amitriptyline serves dual purposes 3
• For patients with hypertension or tachycardia, beta-blockers or candesartan address both conditions 1
• Weight loss is crucial in obese patients as obesity is a risk factor for transformation from episodic to chronic migraine 3

Non-Pharmacological Interventions

• Offer biofeedback, cognitive-behavioral therapy (CBT), and relaxation techniques to all patients as adjuncts or standalone treatments when medications are contraindicated 1
• Exercise 40 minutes three times weekly has been shown as effective as topiramate or relaxation therapy for migraine prevention 1
• Consider neuromodulatory devices as adjunctive therapy 1
• Acupuncture may provide benefit, though evidence shows it is not superior to sham acupuncture 1
• Limited evidence supports physical therapy, spinal manipulation, or specific dietary approaches 1

Patient Education and Lifestyle Modifications

• Educate patients that migraine is a neurological disorder with a biological basis, not a psychological condition 1
• Explain that treatment requires a multimodal approach combining pharmacological and non-pharmacological strategies 1
• Set realistic expectations—chronic migraine management is often a long process requiring patience and treatment adjustments 1
• Identify and manage triggers, though recognize their role is often overestimated 4
• Emphasize regular sleep patterns, stress management, and adequate hydration 7, 2, 8

Referral to Specialist Care

• Refer to a headache specialist for: chronic migraine (≥15 headache days per month), failure of multiple preventive medications, diagnostic uncertainty, or consideration of advanced therapies like Botox or CGRP antibodies 1, 3
• Primary care should maintain long-term management once stable, with clear plans for when to return to specialty care 3

Critical Pitfalls to Avoid

• Never prescribe triptans without screening for cardiovascular disease and risk factors—serious cardiac events including myocardial infarction and death have been reported 5, 6
• Do not delay preventive therapy in patients with frequent migraines—early intervention may prevent progression to chronic migraine 9
• Avoid polypharmacy with acute medications; this increases MOH risk 3
• Do not use neuroimaging routinely for typical migraine presentations; reserve for atypical features or red flags 4
• Recognize that medication overuse headache can mimic chronic migraine—address overuse through patient education and abrupt withdrawal (except for opioids) before establishing preventive treatment 3