How to manage migraines and bowel issues?

Managing Migraines and Bowel Issues

Acute Migraine Treatment

Start with NSAIDs as first-line therapy for acute migraine attacks, specifically ibuprofen (400-800 mg), naproxen sodium (275-550 mg), or aspirin (650-1000 mg), taken early in the headache phase for maximum effectiveness. 1

First-Line Acute Treatment

• NSAIDs have the most consistent evidence for efficacy, including aspirin, ibuprofen, naproxen sodium, and the combination of acetaminophen-aspirin-caffeine 1
• Acetaminophen alone is ineffective for migraine and should not be used as monotherapy 1
• Administer NSAIDs as early as possible when headache begins, ideally while pain is still mild 2

Second-Line Acute Treatment

• If NSAIDs fail after three consecutive attacks, switch to triptans (sumatriptan, rizatriptan, naratriptan, or zolmitriptan) 1
• Triptans work best when taken early in the attack while pain is mild 3
• If one triptan fails, try a different triptan before abandoning the class 1

Third-Line Acute Treatment

• After failure of all available triptans, consider ditans or gepants 1, 3

Managing Nausea and Bowel Issues

For migraine-associated nausea, use antiemetics, but avoid dopamine antagonists (metoclopramide, prochlorperazine) if you have any movement disorders or Parkinson's disease, as these can worsen motor symptoms. 2

Antiemetic Selection

• Standard antiemetics include metoclopramide or prochlorperazine for nausea and vomiting 1, 3
• If you have Parkinson's disease or movement disorders, domperidone is safer due to minimal central nervous system penetration 2
• Consider non-oral routes (nasal spray, injection) if nausea and vomiting occur early in the attack 1

Bowel-Related Considerations

• Avoid opioids for migraine treatment, as they worsen constipation, carry dependency risk, and have questionable efficacy 1, 2, 3
• Limit acute medication use to no more than twice weekly to prevent medication-overuse headache 1, 2

Preventive Therapy Indications

Consider preventive therapy if you experience migraines on ≥2 days per month that adversely affect your life, despite optimized acute treatment. 1

When to Start Prevention

• Two or more migraine attacks per month producing disability for ≥3 days 1
• Using acute medications more than twice per week 1
• Failure of or contraindications to acute treatments 1

First-Line Preventive Medications

Use beta-blockers (propranolol 80-240 mg/day, metoprolol, or timolol 20-30 mg/day), topiramate (target 100 mg/day), or candesartan as first-line preventive options. 1

Beta-Blockers

• Propranolol (80-240 mg/day) and timolol (20-30 mg/day) have the strongest evidence 1
• Use beta-blockers without intrinsic sympathomimetic activity (avoid acebutolol) 1
• Common side effects include dizziness, fatigue, depression, and insomnia, but are generally well-tolerated 1

Topiramate

• Target dose is 100 mg/day, which provides optimal balance of efficacy and tolerability 4, 5, 6
• Start at 25 mg and increase by 25 mg weekly to minimize side effects 4, 5
• Reduces migraine frequency by approximately 2 attacks per month 5, 6
• Most common side effects are paresthesia (tingling), which is dose-related but rarely causes discontinuation 4, 5, 7
• Cognitive dysfunction occurs less frequently than paresthesia but is more troublesome—manage by slow dose titration 7
• Maintain adequate hydration while on topiramate to reduce risk of kidney stones 7
• Topiramate is Pregnancy Category D due to increased risk of cleft lip/palate with first-trimester exposure 7

Candesartan

• Candesartan is an effective first-line option with good evidence 1

Second-Line Preventive Medications

If first-line agents fail, use flunarizine, amitriptyline (30-150 mg/day), or sodium valproate (800-1500 mg/day in men only). 1

Critical Contraindication

• Sodium valproate is strictly contraindicated in women of childbearing potential 1
• Divalproex sodium (500-1500 mg/day) has the same contraindication 1

Amitriptyline

• Dose range 30-150 mg/day 1
• Consider when comorbid depression or sleep disturbances are present 3

Third-Line Preventive Medications

CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) should be reserved for patients who have failed or cannot tolerate first- and second-line preventive medications. 1

CGRP Antibodies

• These are newer agents with regulatory restrictions in Europe limiting use to treatment failures 1
• OnabotulinumtoxinA may also be considered for chronic migraine after other preventive failures 3, 8

Non-Pharmacological Approaches

Consider neuromodulatory devices, biobehavioral therapy, or acupuncture as adjuncts to medication or as stand-alone treatment when medications are contraindicated. 1

Evidence-Based Non-Drug Options

• Relaxation training, thermal biofeedback combined with relaxation, and cognitive behavioral therapy have good evidence 9
• Acupuncture has some evidence, though not superior to sham acupuncture 1
• Physical therapy and spinal manipulation lack evidence and are not recommended 1

Medications to Avoid

Never use oral ergot alkaloids (poorly effective and potentially toxic), and avoid opioids and barbiturates due to dependency risk, medication-overuse headache, and limited efficacy. 1, 2, 3

Specific Contraindications

• Ergotamine should not be used 2
• Butalbital-containing compounds increase risk of medication-overuse headache 1
• Acebutolol, oxcarbazepine, lamotrigine, and telmisartan are ineffective for migraine prevention 9

Monitoring and Duration

• Give preventive medications an adequate trial of 2-3 months before evaluating effectiveness 1, 4
• Topiramate may show efficacy as early as the first month 4
• After achieving stability, consider tapering or discontinuing preventive therapy 1
• Track migraine frequency, severity, duration, disability, and medication response using a headache diary 1, 2