How to manage migraine?

Migraine Management

Acute Treatment Strategy

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen, diclofenac potassium, or aspirin) taken early in the headache phase; for moderate to severe attacks, use triptans as first-line therapy, administered when pain is still mild for maximum effectiveness. 1, 2

First-Line Acute Medications

NSAIDs for Mild-Moderate Attacks:

• Ibuprofen, diclofenac potassium, or acetylsalicylic acid are most effective 1, 2
• Administer early in the headache phase for maximum benefit 1
• Acetaminophen has lower efficacy and should be reserved for patients who cannot tolerate NSAIDs 2

Triptans for Moderate-Severe Attacks:

• Most effective when taken at onset when pain is still mild 2, 3
• Rizatriptan achieves headache response (no or mild pain) in approximately 33% of patients within 2 hours 3
• Subcutaneous sumatriptan is useful for patients who reach maximum pain intensity rapidly or have severe vomiting preventing oral intake 2
• Combining triptans with NSAIDs prevents headache relapse 1

Second-Line and Alternative Acute Medications

When Triptans Fail or Are Contraindicated:

• Ditanes (lasmiditan) or gepants (ubrogepant, rimegepant) are effective alternatives 2
• Antiemetics (domperidone, metoclopramide) treat nausea and vomiting during attacks 2

Medications to Avoid:

• Oral ergot alkaloids are poorly effective and potentially toxic 2
• Opioids and barbiturates have questionable efficacy, considerable adverse effects, and high dependency risk 2, 4

Preventive Treatment Strategy

Initiate preventive therapy for patients experiencing migraine on ≥2 days per month despite optimized acute treatment, starting with beta-blockers (propranolol, metoprolol, atenolol, or bisoprolol) or topiramate as first-line options. 1, 4

First-Line Preventive Medications

Beta-Blockers:

• Propranolol, metoprolol, atenolol, or bisoprolol 1, 4
• Particularly beneficial for patients with comorbid hypertension 4

Topiramate:

• Dose: 50-100 mg oral daily 4
• First choice due to lower cost 2
• Especially beneficial in obese patients (associated with weight loss) 2, 4

Candesartan:

• Angiotensin receptor blocker option 4
• Particularly useful in hypertensive patients 4

Second-Line Preventive Medications

Tricyclic Antidepressants:

• Amitriptyline (10-100 mg oral at night) or nortriptyline 4
• Particularly useful for patients with coexisting anxiety, depression, or sleep disorders 2, 4

Flunarizine:

• Dose: 5-10 mg oral once daily 4
• Effective for patients who fail first-line agents 4
• Avoid in patients with Parkinsonism or depression 4

Valproic Acid:

• Dose: 600-1,500 mg oral once daily 4
• Option for men only 4
• Absolutely contraindicated in women of childbearing potential due to teratogenicity 4

Third-Line Preventive Medications

CGRP Monoclonal Antibodies:

• Erenumab (70 or 140 mg subcutaneous monthly), fremanezumab (225 mg subcutaneous monthly or 675 mg quarterly), galcanezumab, or eptinezumab (100 or 300 mg intravenous quarterly) 1, 4
• Reserved for patients who have failed at least two previous preventive medications 2
• Assess efficacy after 3-6 months 4

OnabotulinumtoxinA:

• Dose: 155-195 units to 31-39 sites every 12 weeks 4
• Approved specifically for chronic migraine (≥15 headache days per month) 2
• Assess efficacy after 6-9 months 4

Treatment Duration and Assessment

• Evaluate treatment response after 2-3 months at therapeutic dose 1, 4
• Continue successful preventive therapy for 6-12 months before considering discontinuation 2, 4
• Failure of one preventive class does not predict failure of others 4

Non-Pharmacological Approaches

Lifestyle Modifications (Recommended for All Patients):

• Identify and avoid migraine triggers 1, 5
• Maintain regular sleep schedule 1, 5
• Eat well-balanced meals at regular times 4
• Maintain adequate hydration 4
• Limit salt/sodium, excessive caffeine, alcohol, and nicotine 4
• Regular exercise 4
• Stress management and relaxation techniques 4, 5

Behavioral Therapies:

• Biofeedback, cognitive-behavioral therapy, and relaxation therapy have favorable efficacy profiles 6
• Can be as effective as pharmacological approaches when combined with medication 4

Nutraceuticals:

• Magnesium citrate, riboflavin (vitamin B2), and coenzyme Q10 have evidence supporting efficacy 6, 5

Monitoring and Follow-Up

Use headache calendars to track:

• Attack frequency, severity, and duration 1
• Medication use patterns 1
• Migraine-related disability 1

Follow-up schedule:

• Evaluate treatment response 2-3 months after initiation or change in treatment 1
• Then every 6-12 months for stable patients 1

Critical Pitfalls to Avoid

Medication Overuse Headache:

• Monitor for acute medication use ≥10 days/month for triptans or ≥15 days/month for NSAIDs 1
• Educate patients about this risk 1, 2
• If medication overuse headache develops, withdraw the causative medication abruptly (except opioids) 2

Red Flags Requiring Further Investigation:

• Apparent late-onset migraine after age 50 should raise suspicion of underlying secondary causes 1
• Sudden onset, fever, neck rigidity, or focal neurological deficits warrant immediate evaluation 2

Comorbidity Management:

• Identify and treat anxiety, depression, sleep disorders, and obesity 1, 2
• Adjust preventive medication selection to address comorbidities (e.g., topiramate for obesity, amitriptyline for depression/sleep disorders) 2

Special Populations

Children and Adolescents:

• Ibuprofen at appropriate weight-based dosing as first-line acute treatment 1
• Propranolol, amitriptyline, or topiramate for prevention 1

Women with Menstrual Migraine:

• Short-term prevention with NSAIDs or triptans 1
• Combined hormonal contraceptives may benefit women with pure menstrual migraine without aura 1

Older Patients:

• Consider comorbidities and potential drug interactions when selecting treatments 1