What are the management options for migraines (episodic or chronic headaches with neurological symptoms)?

From the Guidelines

Migraine management should prioritize preventive therapy with beta blockers, such as propranolol, as first-line treatment, and consider CGRP monoclonal antibodies as third-line medications, according to the most recent and highest quality study 1. For acute treatment, start with NSAIDs like ibuprofen (400-600mg) or naproxen (500-550mg) at the first sign of headache. If these are ineffective, triptans such as sumatriptan (50-100mg orally, 6mg subcutaneously, or 20mg nasal spray) can be used, as recommended by 1.

Key Considerations

• Preventive therapy should be considered for patients with frequent migraines (>2 days per month) despite optimized acute treatment, as suggested by 1.
• Non-pharmacological approaches, including trigger identification and avoidance, maintaining regular sleep patterns, staying hydrated, and practicing stress management techniques like meditation, are also important, as noted by 1.
• CGRP antagonists like erenumab (70-140mg monthly injection) are newer options for prevention, as mentioned in 1.

Treatment Options

• First-line preventive medications include propranolol (40-160mg daily), topiramate (25-100mg daily), and candesartan, as recommended by 1.
• Second-line medications include flunarizine, amitriptyline, and sodium valproate, as suggested by 1.
• Neuromodulatory devices, biobehavioural therapy, and acupuncture can be considered as adjuncts to acute and preventive medication or as stand-alone preventive treatment when medication is contraindicated, as noted by 1.

From the FDA Drug Label

Eletriptan hydrobromide is contraindicated in patients with CAD or Prinzmetal’s variant angina [see Contraindications (4)] Sumatriptan tablets are contraindicated in patients with CAD and those with Prinzmetal’s variant angina.

The management of migraines with eletriptan or sumatriptan requires careful consideration of the patient's cardiovascular risk factors.

• Contraindications: Both drugs are contraindicated in patients with CAD or Prinzmetal’s variant angina.
• Cardiovascular evaluation: A cardiovascular evaluation is recommended for triptan-naive patients with multiple cardiovascular risk factors prior to receiving either drug.
• Medication overuse headache: Overuse of acute migraine drugs, including triptans, can lead to medication overuse headache.
• Serotonin syndrome: Both drugs can cause serotonin syndrome, particularly when co-administered with other serotonergic medications.
• Monitoring: Blood pressure should be monitored in patients treated with either drug, and they are contraindicated in patients with uncontrolled hypertension 2, 3.

From the Research

Management of Migraines

• Migraine management includes avoidance of trigger factors, lifestyle modifications, non-pharmacological therapies, and medications 4
• Pharmacological treatment is traditionally divided into acute or symptomatic treatment, and preventive treatment or prophylaxis 4
• Patients with severe and/or frequent migraines require long-term preventive therapy, while many migraine patients can be treated using only acute treatment 4

Acute Migraine Treatment

• Four nonsteroidal anti-inflammatory drugs (NSAIDs) with randomized controlled trial evidence for efficacy in migraine are ibuprofen, naproxen sodium, diclofenac potassium, and acetylsalicylic acid 5
• Seven triptans are appropriate medications for acute migraine treatment, including sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, and naratriptan 5
• Dihydroergotamine (DHE) is also suitable for selected patients, and antiemetic drugs can be added as necessary 5
• Opioids and combination analgesics containing opioids should not be used routinely 5

Effectiveness of Acute Migraine Medications

• Triptans, ergots, and antiemetics are the top 3 classes of medications with the highest effectiveness, followed by opioids, NSAIDs, and combination analgesics 6
• Individual medications with the highest odds ratios (ORs) were eletriptan (OR 6.1), zolmitriptan (OR 5.7), and sumatriptan (OR 5.2) 6
• Acetaminophen, NSAIDS, combination analgesics, and opioids had ORs mostly around or less than 1, suggesting similar or lower reported effectiveness compared with ibuprofen 6

Systematic Review and Meta-analysis of Acute Migraine Treatments

• Triptans and nonsteroidal anti-inflammatory drugs used individually were significantly associated with reduced pain at 2 hours and 1 day, and increased risk of mild and transient adverse events 7
• Calcitonin gene-related peptide receptor antagonists, lasmiditan, dihydroergotamine, ergotamine plus caffeine, acetaminophen, antiemetics, butorphanol, and tramadol in combination with acetaminophen were significantly associated with pain reduction and increase in mild adverse events 7
• Nonpharmacologic treatments, including remote electrical neuromodulation, transcranial magnetic stimulation, external trigeminal nerve stimulation, and noninvasive vagus nerve stimulation, were significantly associated with improved pain 7