What is the treatment approach for distinguishing and managing migraine vs headache?

Distinguishing and Managing Migraine vs Headache

Suspect migraine when a patient presents with recurrent moderate-to-severe headaches lasting 4-72 hours that are unilateral, pulsating, aggravated by routine activity, and accompanied by nausea/vomiting or photophobia/phonophobia—then treat first-line with NSAIDs (ibuprofen, diclofenac, or aspirin) and escalate to triptans for moderate-to-severe attacks. 1

Diagnostic Approach: When to Suspect Migraine

Key Clinical Features That Distinguish Migraine from Other Headaches

Migraine without aura (most common type) requires at least 5 attacks meeting specific criteria 1:

• Duration: 4-72 hours when untreated 1
• Pain characteristics (at least 2 of the following):
  • Unilateral location (though bilateral occurs in ~40% of cases) 1
  • Pulsating quality 1
  • Moderate or severe intensity 1
  • Aggravation by routine physical activity (walking, climbing stairs) 1
• Associated symptoms (at least 1 required):
  • Nausea and/or vomiting 1
  • Photophobia AND phonophobia 1

Migraine with aura requires at least 2 attacks with fully reversible visual, sensory, speech, motor, brainstem, or retinal symptoms that spread gradually over ≥5 minutes and last 5-60 minutes, followed by headache within 60 minutes 1. Critical distinction from TIA: Aura symptoms spread gradually and occur in succession, whereas TIA symptoms have sudden, simultaneous onset 1.

Chronic migraine is diagnosed when headaches occur ≥15 days/month for >3 months, with migraine features on ≥8 days/month 1.

Red Flags Suggesting Secondary Headache (Not Migraine)

Evaluate urgently for secondary causes when patients present with 2:

• Abrupt onset ("thunderclap" headache)
• Neurologic signs or deficits
• Age ≥50 years at onset
• Presence of cancer or immunosuppression
• Provocation by physical activities or postural changes

Diagnostic Workup

Medical history is the mainstay of diagnosis 1. Document:

• Age at onset (typically at or around puberty for migraine) 1
• Attack frequency, duration, and severity 1
• Pain location, quality, and aggravating factors 3
• Family history (migraine has strong genetic component) 1, 3

Physical examination is confirmatory; neuroimaging should only be used when secondary headache disorder is suspected 1.

Acute Treatment Algorithm

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

Start with NSAIDs: acetylsalicylic acid (aspirin), ibuprofen, or diclofenac potassium 1. These are first-line for mild-to-moderate migraine 4. Acetaminophen is also effective for mild attacks 2, 4.

Critical pitfall: Medication overuse headache (MOH) occurs with NSAID use ≥15 days/month 3. Monitor acute medication frequency closely 1.

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

Triptans are first-line for moderate-to-severe migraine 4. They eliminate pain in 20-30% of patients by 2 hours 2. Sumatriptan tablets (25mg, 50mg, or 100mg) achieve headache response (reduction to mild or no pain) in 52-62% at 2 hours and 65-79% at 4 hours, compared to 17-27% and 19-38% with placebo 5.

When triptans provide insufficient relief, combine with fast-acting NSAIDs 1.

Contraindications: Avoid triptans in patients with or at high risk for cardiovascular disease due to vasoconstrictive properties 2. Adverse effects include transient flushing, tightness, or tingling in upper body in 25% of patients 2.

Third-Line: Newer Agents

Gepants (rimegepant, ubrogepant): CGRP receptor antagonists eliminate headache in 20% at 2 hours, with nausea and dry mouth in 1-4% 2.

Lasmiditan: 5-HT1F agonist, safe in patients with cardiovascular risk factors 2.

Route Selection Based on Symptoms

Use nonoral routes when nausea/vomiting is prominent early in the attack 1. Treat nausea itself as a disabling symptom requiring antiemetic therapy, not just when vomiting occurs 1.

Preventive Therapy Indications and Selection

When to Initiate Prevention

Consider preventive therapy when 3, 6:

• ≥2 days per month adversely affected despite optimized acute treatment 3
• ≥4 headache attacks per month 1, 6
• ≥8 headache days per month 6
• Contraindication to or failure of acute treatments 1
• Acute medication use >2 times per week (≥10 days/month) 1, 6

First-Line Preventive Medications

Established as effective 6:

• Propranolol: 80-240 mg/day 1, 6
• Timolol: 20-30 mg/day 1, 6
• Metoprolol 6
• Topiramate: 50-100 mg/day 1, 6
• Divalproex sodium: 500-1500 mg/day 1, 6

Second-Line Options

Probably effective 3, 6:

• Amitriptyline: 10-100 mg at night, particularly with comorbid sleep disturbances 1, 3
• Venlafaxine 6
• Candesartan 3, 6

Third-Line: Newer Biologics

CGRP monoclonal antibodies (erenumab 70-140mg subcutaneous monthly, fremanezumab 225mg monthly or 675mg quarterly, eptinezumab 100-300mg IV quarterly) reduce migraine by 1-3 days per month relative to placebo 1, 2.

OnabotulinumtoxinA: 155-195 units to 31-39 sites every 12 weeks for chronic migraine 1.

Special Population Considerations

Children and Adolescents

• Bed rest alone may suffice 1
• Acute treatment: Ibuprofen 1
• Prevention: Propranolol, amitriptyline, or topiramate 1

Pregnant/Breastfeeding Women

• Acute treatment: Paracetamol (acetaminophen) only 1, 3
• Avoid preventive treatment if possible 1, 3

Older Adults

• Higher risk of secondary headache, comorbidities, and adverse events 1
• Monitor cardiovascular risk factors carefully with triptans 3

Women with Menstrual Migraine

• Perimenstrual prevention: Long-acting NSAID (naproxen) or triptan (frovatriptan, naratriptan) for 5 days starting 2 days before expected menstruation 1
• Contraindication: Combined hormonal contraceptives are contraindicated in migraine with aura due to increased stroke risk 1

Monitoring and Treatment Optimization

Follow-Up Timeline

• Evaluate treatment response 2-3 months after initiation or change 1
• Regular follow-up every 6-12 months thereafter 1, 3

Assessment Tools

• Headache calendars: Track attack frequency, severity, duration, disability, and medication use 1, 3
• mTOQ-4: Evaluate acute medication effectiveness 1
• HURT questionnaire: Assess intervention effectiveness 1
• HIT-6: Monitor progress 3

When Treatment Fails

Before concluding failure, review 1:

• Diagnosis accuracy
• Treatment strategy appropriateness
• Dosing optimization (some benefit from higher doses, others from lower doses with fewer adverse effects)
• Adherence issues

Consider discontinuing preventive medication after 3-6 months of stability to determine if prophylaxis is still needed 3.

Critical Pitfalls to Avoid

Medication overuse headache (MOH): Occurs with regular overuse >3 months of non-opioid analgesics ≥15 days/month or other acute medications ≥10 days/month 1. Management: Withdraw overused medication, preferably abruptly 1. Specialist referral indicated for chronic migraine 1.

Sodium valproate: Absolutely contraindicated in women of childbearing potential 1.

Patient education: Benefits of preventive medications may take several weeks to become apparent—encourage adherence 3. Provide realistic expectations about treatment outcomes 1.