What are the management options for a patient experiencing migraines?

Migraine Management

Migraine management requires a dual approach: acute treatment with NSAIDs or triptans for active attacks, and preventive therapy for patients experiencing ≥2 days of migraine per month despite optimized acute treatment. 1

Initial Assessment and Diagnosis

Rule out secondary causes of headache before initiating migraine-specific therapy. 1

• Suspect migraine when patients present with recurrent moderate-to-severe headache, particularly with visual aura, family history, and symptom onset around puberty 2
• Use neuroimaging only when secondary headache disorders are suspected 2
• Implement a headache diary to track severity, frequency, duration, disability, treatment response, and triggers 1
• Apply standardized assessment tools (HIT-6 and MSQ) to measure impact and guide treatment decisions 1

Acute Attack Management

First-Line Acute Treatments

NSAIDs are the initial treatment of choice for acute migraine attacks. 2, 3

• Aspirin, ibuprofen, and diclofenac potassium have proven efficacy 2, 3
• Acetaminophen/paracetamol has lower efficacy and should be reserved for patients intolerant to NSAIDs 2, 3
• Limit acute medication use to no more than twice weekly (≤10 days/month) to prevent medication overuse headache 1, 2, 3

Triptans for Moderate-to-Severe Attacks

Triptans are most effective when taken early in an attack while pain is still mild. 4, 2, 3

• Available triptans include sumatriptan, rizatriptan, zolmitriptan, naratriptan, almotriptan, frovatriptan, and eletriptan 4
• If one triptan fails, try another—failure of one does not predict failure of others 4
• Subcutaneous sumatriptan is preferred for patients with rapid pain escalation or severe vomiting 4, 3
• Contraindications include coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, stroke/TIA history, and Wolff-Parkinson-White syndrome 5
• Perform cardiovascular evaluation in triptan-naive patients with multiple cardiovascular risk factors before prescribing 5

Alternative Acute Treatments

• Ditanes (lasmiditan) or gepants (ubrogepant, rimegepant) for patients who fail or have contraindications to triptans 4, 3
• Antiemetics (domperidone, metoclopramide) for nausea and vomiting 4, 2, 3
• Avoid oral ergot alkaloids (poor efficacy, potentially toxic), opioids, and barbiturates (questionable efficacy, considerable adverse effects, dependency risk) 4, 2, 3

Preventive Therapy

Indications for Preventive Treatment

Initiate preventive therapy when migraine affects quality of life ≥2 days per month despite optimized acute treatment. 4

• Other indications include: excessive acute medication use (≥10 days/month), contraindications to acute medications, patient preference, or very frequent attacks 1, 6
• Medication overuse is itself an indication for preventive therapy 1, 4

First-Line Preventive Medications

Beta-blockers (propranolol, metoprolol, atenolol, bisoprolol) are first-line agents, particularly beneficial in patients with comorbid hypertension or tachycardia. 4, 7

• Topiramate 50-100 mg daily is first-line, especially beneficial in obese patients due to associated weight loss 4, 2, 3
• Candesartan is first-line for patients with comorbid hypertension 4, 7
• Assess efficacy of oral preventive medications after 2-3 months at therapeutic dose 4, 2, 3

Second-Line Preventive Options

• Flunarizine 5-10 mg daily for patients who fail first-line agents (avoid in Parkinsonism or depression) 4
• Amitriptyline or nortriptyline for patients with coexisting anxiety, depression, or sleep disorders 4, 7
• Valproic acid 600-1,500 mg daily for men only—absolutely contraindicated in women of childbearing potential due to teratogenicity 4

Third-Line and Refractory Cases

For chronic migraine (≥15 headache days/month), onabotulinumtoxinA 155-195 units to 31-39 sites every 12 weeks is effective. 4, 2, 3

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) for patients who have failed ≥2 first- or second-line preventive medications 4, 2, 3
• Assess CGRP antibody efficacy after 3-6 months 4, 2
• Assess onabotulinumtoxinA efficacy after 6-9 months 4, 2

Treatment Duration

Continue successful preventive therapy for 6-12 months, then consider pausing to determine if ongoing prevention is still needed. 4, 3

Non-Pharmacological Interventions

Cognitive-behavioral therapy and biofeedback should be offered to all patients as they provide relief comparable to pharmacological approaches. 1

• Additional effective therapies include relaxation training, progressive muscle relaxation, meditation, and guided imagery 1
• Exercise 40 minutes three times weekly is as effective as topiramate or relaxation therapy 1
• Biobehavioral therapy can be combined with medications for enhanced efficacy 4
• Neuromodulatory devices may be considered when medications are contraindicated 4

Lifestyle Modifications and Trigger Management

Implement dietary and lifestyle modifications as foundational interventions for all patients. 4

• Limit salt/sodium, avoid excessive caffeine, alcohol, and nicotine 4
• Maintain regular sleep patterns, eat well-balanced meals at regular times, ensure adequate hydration 4
• Manage stress through relaxation techniques 1, 4
• Regular exercise should be encouraged 1, 4
• The role of trigger avoidance is often overestimated—focus on lifestyle regularity rather than extensive trigger elimination 2

Management of Comorbidities

Identify and treat comorbid conditions (anxiety, depression, sleep disorders, obesity) as they significantly impact migraine outcomes. 1, 2, 3

• Tailor preventive medication selection to address comorbidities:
  • Topiramate for obesity (promotes weight loss) 4, 2, 3
  • Amitriptyline for depression or sleep disorders 4, 2, 3
  • Beta-blockers for hypertension or tachycardia 1, 4
  • Candesartan for hypertension 4

Medication Overuse Headache (MOH)

Educate all patients that using acute medications ≥10 days per month risks medication overuse headache, which presents as daily migraine-like headaches or marked increase in attack frequency. 1, 2, 3, 5

• Management requires explanation, withdrawal of the overused medication (preferably abrupt except for opioids), and initiation of preventive therapy 2, 3
• Expect transient worsening of headache during withdrawal 5
• Monitor acute medication use closely at every visit 1

Critical Pitfalls to Avoid

• Never prescribe opioids or barbiturates—they have questionable efficacy, considerable adverse effects, and high dependency risk 4, 2, 3
• Avoid oral ergot alkaloids due to poor efficacy and potential toxicity 2, 3
• Do not abandon preventive treatment prematurely—efficacy takes weeks to months to establish 4
• Screen for cardiovascular risk factors before prescribing triptans and perform cardiovascular evaluation in high-risk patients 5
• Do not use vestibular suppressants for long-term management 4
• Recognize that failure of one preventive medication does not predict failure of other drug classes 4

Patient Education and Expectations

Educate patients that migraine is a neurological disorder with a biological basis requiring multimodal therapy. 1

• Set realistic expectations—efficacy is rarely immediate and may take several weeks to months 1, 4
• Emphasize that treatment adherence improves with simplified dosing schedules 4
• Patient empowerment through education and establishing realistic expectations is key to improving quality of life 1

Long-Term Follow-Up

Long-term migraine management should be the responsibility of primary care, with specialist referral reserved for refractory cases or when chronic migraine does not improve with treatment. 1, 2, 3

• Use headache diaries to monitor frequency, intensity, and treatment response 1, 2, 3
• Reassess treatment efficacy at appropriate intervals based on medication class 4, 2
• Refer to headache specialists when primary headache disorder does not improve despite comprehensive management 1