What are the best options for managing migraines?

Kyleena and Migraine Management

Direct Answer

If you are asking about migraine management in a patient using Kyleena (levonorgestrel IUD), treat migraines using the standard stepped-care approach: start with NSAIDs (ibuprofen 400 mg, naproxen, or aspirin) for mild-to-moderate attacks, and escalate to triptans for moderate-to-severe attacks or when NSAIDs fail. 1 There are no specific contraindications to standard migraine therapies in patients using hormonal IUDs like Kyleena.

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Acute Migraine Treatment Algorithm

First-Line: NSAIDs for Mild-to-Moderate Attacks

• Start with ibuprofen 400 mg, aspirin, naproxen sodium, or diclofenac potassium as first-line therapy for mild-to-moderate migraine attacks 1
• Ibuprofen 400 mg provides 2-hour headache relief in 57% of patients (versus 25% with placebo), with an NNT of 3.2 2
• Take medication as early as possible during the attack to maximize efficacy 1
• Acetaminophen alone is less effective and should only be used if NSAIDs are not tolerated 1
• Combination therapy with aspirin + acetaminophen + caffeine can be effective for mild-to-moderate attacks 1, 3

Second-Line: Triptans for Moderate-to-Severe Attacks

• Offer triptans when NSAIDs provide inadequate relief or for moderate-to-severe attacks from the outset 1
• All triptans have well-documented effectiveness; if one fails, try another 1
• Administer triptans early when headache is still mild for maximum benefit 1, 4
• Combining a triptan with an NSAID (e.g., naproxen) improves efficacy beyond either agent alone 1, 3
• Oral options include sumatriptan, rizatriptan, naratriptan, and zolmitriptan 1

Non-Oral Routes for Nausea/Vomiting

• Use non-oral administration when significant nausea or vomiting is present 1
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% pain-free at 2 hours) 5
• Intranasal sumatriptan (5-20 mg) or nasal spray triptans are effective alternatives 5, 4

Adjunctive Antiemetic Therapy

• Add metoclopramide 10 mg or prochlorperazine 10 mg to treat nausea and provide synergistic analgesia 1, 5
• Antiemetics should not be restricted only to patients who are vomiting—nausea itself is disabling and warrants treatment 1

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Critical Cautions

Medication Overuse Headache

• Limit acute medication use to prevent medication overuse headache: ≤15 days/month for NSAIDs, ≤10 days/month for triptans 3, 6
• Overuse of acute medications (≥10 days/month) can lead to rebound headaches and worsening migraine frequency 1
• If using acute medications more than twice per week, consider preventive therapy 1, 4

Avoid Opioids and Butalbital

• Opioids should be avoided for migraine treatment as they lead to dependency, rebound headaches, and loss of efficacy 1, 5
• Reserve opioids only for cases where other medications cannot be used and abuse risk has been addressed 1, 5

Triptan Contraindications

• Triptans are contraindicated in patients with coronary artery disease, uncontrolled hypertension, stroke/TIA history, or hemiplegic migraine 6, 7
• Monitor for chest/throat/jaw tightness after triptan use; if cardiac origin suspected, evaluate before further use 6, 7

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When to Consider Preventive Therapy

Initiate preventive treatment if: 1, 4

• Two or more attacks per month producing disability lasting ≥3 days
• Contraindication to or failure of acute treatments
• Use of acute medication more than twice per week
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura)

First-Line Preventive Options

• Beta-blockers (propranolol 80-240 mg/day, metoprolol, atenolol, bisoprolol) 1
• Topiramate 64 mg/day (discuss teratogenic effects with women of childbearing potential) 1, 3
• Candesartan 1

Second-Line Preventive Options

• Amitriptyline 30-150 mg/day 1
• Flunarizine 1
• Sodium valproate (contraindicated in women of childbearing potential) 1

Third-Line: CGRP Monoclonal Antibodies

• Erenumab, fremanezumab, galcanezumab, or eptinezumab 1
• Reserved for patients who have failed other preventive medications 1

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Lifestyle Modifications

• Maintain regular sleep schedule, adequate hydration, and regular meals 3, 4
• Engage in regular moderate-to-intense aerobic exercise 3, 4
• Manage stress with relaxation techniques or mindfulness 3, 4
• Address poor sleep quality and physical fitness as predisposing factors 1, 4

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Monitoring and Follow-Up

• Have patients maintain a headache diary tracking frequency, severity, duration, disability, treatment response, and adverse effects 1, 4
• Use the diary to determine treatment efficacy, identify analgesic overuse, and monitor migraine progression 3, 4
• Switch treatments if adequate response is not achieved during a reasonable trial period 3