From the Guidelines
The goal for controlled migraine is typically fewer than 4 migraine days per month, as achieving this target indicates good management of the condition and significantly reduces the impact on quality of life. For patients with chronic migraine (15 or more headache days per month), a 50% reduction in headache frequency is considered a meaningful improvement 1. Effective control often requires a combination of preventive medications (such as topiramate, propranolol, amitriptyline, or CGRP antagonists like erenumab or fremanezumab) and acute treatments (triptans, NSAIDs, or gepants) 1.
Key Considerations
- Lifestyle modifications including regular sleep patterns, stress management, consistent meals, and trigger avoidance are equally important components of migraine management.
- Patients should maintain a headache diary to track frequency, severity, triggers, and medication effectiveness, which helps in evaluating if the goal of fewer than 4 migraines monthly is being achieved.
- The choice of preventive therapy should be based on the individual patient's needs and medical history, with options including beta blockers, topiramate, and CGRP monoclonal antibodies 1.
Preventive Therapy
- Candesartan or telmisartan are recommended for the prevention of episodic migraine 1.
- Erenumab, fremanezumab, or galcanezumab are recommended for the prevention of episodic or chronic migraine 1.
- Topiramate, propranolol, and valproate may also be considered for preventive therapy, although the evidence is weaker 1.
Acute Treatment
- Eletriptan, frovatriptan, rizatriptan, sumatriptan, and zolmitriptan are recommended for the short-term treatment of migraine 1.
- Aspirin-acetaminophen-caffeine, acetaminophen, aspirin, ibuprofen, and naproxen may also be considered for acute treatment 1.
From the Research
Migraine Episode Frequency
To be considered controlled, the goal for migraine episodes in a month is:
- Four or fewer monthly headache days per month, as this provides a clinically meaningful therapeutic target for patients with chronic migraine 2
- Fewer than 15 days per month for episodic migraine, according to the International Classification of Headache Disorders (third revision) beta diagnostic criteria 3
Key Points
- Reducing headache frequency to ≤4 monthly headache days is associated with improved patient-reported outcomes and less acute medication use 2
- The choice of prophylactic drugs for migraine prevention depends on efficacy, co-morbidity, side effects, availability, and cost 4
- Botulinum toxin type A has been shown to be safe and well tolerated for the prophylactic treatment of episodic migraine, but its efficacy is still being studied 5
- First-line agents for migraine prevention include propranolol, timolol, amitriptyline, divalproex, sodium valproate, and topiramate 6