Management of Migraine
Acute Treatment Strategy
For mild to moderate migraine attacks, start with NSAIDs (aspirin 650-1000 mg, ibuprofen 400-800 mg, or naproxen sodium 275-550 mg) combined with a prokinetic antiemetic (metoclopramide 10 mg or domperidone) if nausea is present. 1, 2
Acute Treatment Algorithm by Severity
Mild to Moderate Attacks:
- First-line: NSAIDs (oral) plus caffeine-containing combination analgesics 1
- Aspirin 650-1000 mg every 4-6 hours (maximum 4 g/day) 1
- Ibuprofen 400-800 mg every 6 hours (maximum 2.4 g/day) 1
- Naproxen sodium 275-550 mg every 2-6 hours (maximum 1.5 g/day) 1
- Treat early when headache is still mild for maximum effectiveness 3
Moderate to Severe Attacks or Poor Response to NSAIDs:
- Migraine-specific agents (triptans) are indicated when NSAIDs fail 1
- Oral triptans with good evidence: naratriptan, rizatriptan, zolmitriptan 1
- Subcutaneous sumatriptan for fastest onset 1
- DHE nasal spray as alternative 1
Attacks with Early Nausea/Vomiting:
- Use non-oral routes of administration (nasal spray, subcutaneous, intramuscular, or suppository) 1
- Metoclopramide 10 mg IV or orally 20-30 minutes before or with analgesic/NSAID 1
- Prochlorperazine can effectively relieve both headache pain and nausea 1
Critical Limitation: Restrict acute medication use to no more than twice weekly to prevent medication overuse headache (MOH), which is the most severe complication and risk factor for chronic migraine 2, 4
Medications to Avoid
Avoid ergot alkaloids, opioids (except as rescue), and barbiturates due to questionable efficacy, high risk of dependency, and medication overuse headache 2
- Opiates (meperidine 50-150 mg IM/IV) and butorphanol nasal spray may be considered only as rescue medication when sedation is acceptable and abuse risk has been addressed 1
Preventive Therapy Indications
Consider preventive therapy when migraine adversely affects the patient ≥2 days per month despite optimized acute treatment, or when acute medications are used more than twice weekly. 1, 2, 3
Specific Indications for Prevention:
- Two or more attacks per month producing disability lasting ≥3 days per month 1
- Contraindication to or failure of acute treatments 1
- Use of abortive medication more than twice per week 1
- Uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction) 1
Preventive Medication Algorithm
First-Line Preventive Agents:
Beta-blockers without intrinsic sympathomimetic activity are first-line for episodic migraine: 1, 3, 5
- Propranolol 80-240 mg/day (FDA-approved for migraine prophylaxis) 1, 5
- Timolol 20-30 mg/day 1
- Metoprolol, atenolol, or bisoprolol 3
Topiramate 100 mg/day (titrate gradually) is first-line for chronic migraine and particularly beneficial in obese patients due to weight loss effect. 2, 3
Amitriptyline 30-150 mg/day is first-line, especially when comorbid depression or sleep disorders exist 1
Divalproex sodium 500-1500 mg/day or sodium valproate 800-1500 mg/day are first-line options 1
Advanced Therapies for Chronic Migraine:
OnabotulinumtoxinA is indicated for chronic migraine (≥15 headache days/month) after failure of topiramate and at least one other preventive medication. 2
CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) are reserved for patients who have failed at least two to three other preventive medications due to regulatory restrictions and high cost 2
Chronic Migraine Management
Chronic migraine is defined as ≥15 headache days per month for at least 3 months, with migraine features on at least 8 days per month. 2
Critical First Step:
Rule out medication overuse headache (MOH) before initiating preventive therapy, as MOH frequently mimics chronic migraine and will prevent response to preventive medications 2, 4
- MOH occurs when acute medications are used ≥10 days per month 4
- Requires withdrawal of overused medications before preventive therapy can work 2, 4
Monitoring Tools:
- Implement headache diary to track frequency, severity, triggers, and medication use 2, 3
- Use validated assessment tools: Headache Impact Test-6 (HIT-6) and Migraine-Specific Quality-of-Life Questionnaire (MSQ) 2, 3
Comorbidity Management
Identify and treat comorbid conditions—depression, anxiety, sleep disorders, obesity, and chronic pain—as their management directly improves migraine outcomes. 2, 4, 3
Critical Modifiable Risk Factors:
- Obesity is the single most critical modifiable risk factor for transformation from episodic to chronic migraine and must be aggressively addressed 4
- Weight loss is particularly crucial, making topiramate an especially beneficial preventive choice 4, 3
- Poor sleep quality and irregular sleep patterns increase attack susceptibility—emphasize regular sleep schedules 4, 3
Non-Pharmacological Interventions
Offer cognitive-behavioral therapy (CBT), biofeedback, and relaxation training to all patients, as these have proven efficacy comparable to pharmacological treatments. 2, 3
Regular exercise (40 minutes three times weekly) is as effective as topiramate or relaxation therapy for migraine prevention. 4, 3
Additional lifestyle modifications: 3
- Regular sleep patterns and stress management 3
- Adequate hydration and regular eating 4
- Avoiding excessive caffeine, alcohol, and nicotine 4
Patient Education
Educate patients that migraine is a neurological disorder with a biological basis requiring multimodal treatment, not a psychological condition. 2, 3
Set realistic expectations: The goal is to reduce attack frequency, duration, and intensity to minimize disability, not complete elimination of all headaches 1, 2
Chronic migraine management is often a long process requiring patience and treatment adjustments. 3
Specialist Referral Indications
Refer to a headache specialist for: 2, 3
- Confirmed chronic migraine diagnosis (≥15 headache days/month) 2, 3
- Failure of multiple preventive medications 2, 3
- Consideration of onabotulinumtoxinA or CGRP antibodies 2, 3
- Diagnostic uncertainty 2, 3
Specialist care is usually necessary for optimal chronic migraine management. 2
Critical Pitfalls to Avoid
Never initiate preventive therapy without first ruling out and treating medication overuse headache, as MOH will prevent response to preventive medications 2
Never allow unlimited acute medication use—strict limitation to twice weekly prevents progression and medication overuse headache 2, 4
Do not overemphasize trigger avoidance, as this can lead to unnecessary avoidance behavior that damages quality of life 4