What are the triggers and treatment options for migraine?

Migraine Triggers and Treatment

Migraine Triggers

While trigger identification is often overemphasized, menstruation stands out as the most clinically significant trigger, with some women experiencing exclusively menstruation-related attacks. 1

Key Points About Triggers

• True trigger factors are typically self-evident to patients and do not require extensive investigation 1
• Predisposing factors (poor sleep quality, poor physical fitness, stress) increase susceptibility to attacks, while aggravating factors (physical activity) worsen headache during an attack 1
• Avoid unnecessary trigger avoidance behavior that can damage quality of life 1
• Lifestyle modifications should focus on: staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, engaging in regular moderate-to-intense aerobic exercise (40 minutes, three times weekly), managing stress with relaxation techniques, and weight loss for those who are overweight 1, 2

Acute Treatment Algorithm

First-Line: Mild to Moderate Migraine

Start with NSAIDs (ibuprofen, aspirin, or diclofenac potassium) or acetaminophen for mild to moderate attacks. 1

• The combination of aspirin, acetaminophen, and caffeine is strongly recommended with a number needed to treat of 9 for pain freedom at 2 hours 2
• Begin treatment as soon as possible after migraine onset to improve efficacy 1

Second-Line: Moderate to Severe Migraine

For moderate to severe migraine, use combination therapy with a triptan plus an NSAID or acetaminophen from the start. 1

• All triptans have well-documented effectiveness, with sumatriptan, zolmitriptan, rizatriptan, and almotriptan being evidence-based options 1
• Triptans are most effective when taken early in an attack while headache is still mild, but should not be used during the aura phase 1
• If one triptan is ineffective, try another triptan or a different NSAID-triptan combination 1

Third-Line: Refractory Cases

Consider CGRP antagonists (gepants: rimegepant, ubrogepant, zavegepant) or ergot alkaloids (dihydroergotamine) for patients who do not tolerate or have inadequate response to triptan-NSAID combination therapy. 1

• Lasmiditan (ditan) should be reserved for patients who fail all other pharmacologic treatments 1
• Never use opioids or butalbital for acute episodic migraine treatment 1

Special Situations

For severe nausea or vomiting, use a non-oral triptan (subcutaneous sumatriptan, nasal zolmitriptan or sumatriptan) plus an antiemetic. 1

• Subcutaneous sumatriptan is useful for patients who rapidly reach peak headache intensity or cannot take oral medications 1
• For headache relapses (return of symptoms within 48 hours), patients can repeat triptan treatment or combine with fast-acting naproxen 1

Critical Safety Warnings

Medication Overuse Headache

Patients must be counseled about medication overuse headache, defined as headache occurring ≥15 days per month for at least 3 months due to overuse of acute medication. 1

• The threshold varies by treatment: ≥15 days per month with NSAIDs; ≥10 days per month with triptans 1
• Overuse of acute migraine drugs can lead to exacerbation of headache requiring detoxification and withdrawal 3

Cardiovascular Contraindications

Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's variant angina, uncontrolled hypertension, stroke, or TIA. 3

• Cerebrovascular events including hemorrhage and stroke have occurred with 5-HT1 agonists 3
• Perform cardiac evaluation in high-risk patients experiencing chest, throat, neck, or jaw pain/tightness after triptan use 3

Pregnancy and Lactation

In patients of childbearing potential, pregnant, or breastfeeding, discuss adverse effects of pharmacologic treatments during pregnancy and lactation. 1

• Topiramate and valproate have teratogenic effects; advise effective birth control and folate supplementation 1

Preventive Treatment

Indications for Prevention

Consider preventive therapy for patients with ≥2 attacks per month producing disability for ≥3 days per month, contraindication or failure of acute treatments, or use of acute medication more than twice weekly. 2

• If episodic migraine occurs frequently or acute treatment provides inadequate response, preventive medications are warranted 1

First-Line Preventive Options

The most favorable evidence-based preventive treatments include (in alphabetical order): amitriptyline, beta-blockers (propranolol), topiramate, and erenumab (CGRP receptor antibody). 2, 4

• Topiramate is recommended as first-line due to lower cost, but requires discussion of teratogenic effects with patients of childbearing age 2
• For chronic migraine specifically, onabotulinumtoxinA is effective 2, 4
• In children and adolescents, discuss that placebo was as effective as studied medications in many trials before starting preventive therapy 1

Non-Pharmacological Prevention

Cognitive-behavioral therapy, biofeedback, and relaxation training should be offered to all patients as part of comprehensive management. 2

• Regular moderate-to-intense aerobic exercise (40 minutes, three times weekly) is as effective as some preventive medications 2

Pediatric Considerations

For children and adolescents, use ibuprofen as first-line acute treatment; in adolescents, consider sumatriptan/naproxen combination, nasal zolmitriptan or sumatriptan, rizatriptan ODT, or almotriptan. 1

• For prevention in pediatrics, discuss evidence for amitriptyline combined with cognitive behavioral therapy, topiramate, and propranolol 1