What is the recommended evaluation and treatment approach for a patient presenting with migraines?

Migraine Evaluation and Treatment

Initial Evaluation

Begin with a focused headache history that specifically addresses pain characteristics, associated symptoms, triggers, and red flags for secondary causes. 1

Critical History Elements

• Pain characteristics: Location (unilateral vs bilateral), quality (throbbing vs other), intensity, duration, and frequency 1
• Associated symptoms: Nausea, vomiting, photophobia, phonophobia, visual disturbances, or aura 1
• Temporal patterns: Time of onset, duration of attacks, frequency per month, and whether headaches awaken the patient from sleep 1
• Triggers: Specific foods, beverages, stress, weather changes, odors, missed meals, or menstrual cycle 1
• Current medication use: Over-the-counter medications, prescription drugs, frequency of use, and effectiveness 1
• Family history: Migraine or other headache disorders in relatives 1
• Comorbidities: Epilepsy, anxiety, depression, connective tissue disorders, cardiovascular disease, or hypertension 1

Red Flags Requiring Neuroimaging

Consider neuroimaging in patients with unexplained abnormal neurologic examination findings, or when headaches have atypical features that don't meet strict migraine criteria. 1

• Headache worsened by Valsalva maneuver 1
• Headache that awakens patient from sleep 1
• New-onset headache in older patients 1
• Progressively worsening headache pattern 1
• Thunderclap onset, fever with neck stiffness, or focal neurologic deficits 2

In patients with normal neurologic examination and typical migraine features, neuroimaging is usually not warranted. 1

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Acute Treatment Strategy

First-Line Treatment for Mild to Moderate Migraine

Start with NSAIDs as initial therapy, specifically ibuprofen 400-800 mg, naproxen sodium 500-825 mg, aspirin 1000 mg, or diclofenac potassium, taken as early as possible when pain is still mild. 2, 3, 4

• Acetaminophen 1000 mg has inferior efficacy and should only be used if NSAIDs are contraindicated 3
• Combination therapy with acetaminophen, aspirin, and caffeine is effective when NSAIDs alone are insufficient 1, 2
• Early administration during the attack significantly improves efficacy 2, 3, 4

First-Line Treatment for Moderate to Severe Migraine

Add a triptan to an NSAID for moderate to severe migraine, with sumatriptan 50-100 mg plus naproxen sodium 500 mg being the most evidence-based combination. 2, 3, 4

• Sumatriptan 50-100 mg achieves headache response in 50-62% of patients at 2 hours versus 17-27% with placebo 3, 5
• The combination of triptan plus NSAID is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 2
• Other effective oral triptans include rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, and naratriptan 2, 6, 7

Route Selection Based on Severity and Symptoms

For patients with rapid progression to peak intensity or significant nausea/vomiting, use subcutaneous sumatriptan 6 mg, which provides pain relief in 70-82% of patients within 15 minutes. 2, 4

• Subcutaneous sumatriptan achieves the highest efficacy rates among all routes of triptan administration 2
• Intranasal sumatriptan 5-20 mg is an alternative for patients with nausea who cannot tolerate oral medications 2

Dosing Guidelines for Sumatriptan

• Initial dose: 25 mg, 50 mg, or 100 mg orally 5
• Doses of 50 mg and 100 mg provide greater effect than 25 mg, but 100 mg may not provide greater effect than 50 mg 5
• If migraine has not resolved by 2 hours, a second dose may be administered at least 2 hours after the first dose 5
• Maximum daily dose is 200 mg in a 24-hour period 5
• In patients with mild to moderate hepatic impairment, maximum single dose should not exceed 50 mg 5

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Intravenous Treatment for Severe Migraine

For severe migraine requiring IV treatment, use metoclopramide 10 mg IV plus ketorolac 30 mg IV as first-line combination therapy. 2

• Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism, beyond its antiemetic properties 2, 3
• Ketorolac has rapid onset with approximately 6 hours duration and minimal rebound headache risk 2
• Prochlorperazine 10 mg IV is an alternative to metoclopramide with comparable efficacy 2
• Dihydroergotamine (DHE) IV or intranasal has good evidence for efficacy as monotherapy 2

Avoid opioids for migraine treatment as they lead to dependency, rebound headaches, and eventual loss of efficacy. 2, 3

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Alternative Treatments When Triptans Are Contraindicated

CGRP Antagonists (Gepants)

Use gepants (ubrogepant 50-100 mg or rimegepant) as the primary oral alternative for moderate to severe migraine when triptans are contraindicated due to cardiovascular disease, uncontrolled hypertension, or cerebrovascular disease. 2

• Gepants have no vasoconstriction, making them safe for patients with cardiovascular contraindications 2

Ditans

Lasmiditan 50-200 mg is a 5-HT1F receptor agonist without vasoconstrictor activity, suitable as a second-line alternative when gepants are unavailable or ineffective. 2

• Patients must not drive or operate machinery for at least 8 hours after taking lasmiditan due to CNS effects (dizziness, vertigo, somnolence, fatigue) 2

Contraindications to Triptans

Triptans are contraindicated in patients with ischemic heart disease, coronary artery vasospasm (Prinzmetal's angina), uncontrolled hypertension, stroke, TIA, Wolff-Parkinson-White syndrome, or other cardiac accessory conduction pathway disorders. 5

• Perform cardiovascular evaluation in triptan-naive patients with multiple cardiovascular risk factors before prescribing 5
• Consider administering first dose in medically supervised setting with ECG monitoring for high-risk patients 5

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Critical Medication Frequency Limits

Strictly limit all acute migraine medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache. 2, 3, 4

• Medication-overuse headache occurs with frequent use of triptans (≥10 days/month), NSAIDs (≥15 days/month), ergotamine, opiates, or analgesics 1, 5
• Overuse leads to increasing headache frequency and potentially daily headaches 1, 2
• Detoxification with withdrawal of overused drugs may be necessary 5

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Preventive Therapy Indications

Initiate preventive therapy immediately for patients with ≥2 disabling attacks per month, inadequate response to optimized acute treatment, or use of acute medications >2 days per week. 2, 3, 4

First-Line Preventive Medications

• Beta-blockers: Propranolol 80-240 mg/day, timolol 20-30 mg/day, atenolol, bisoprolol, or metoprolol 2, 3, 4
• Tricyclic antidepressants: Amitriptyline 30-150 mg/day, particularly for patients with mixed migraine and tension-type headache 2, 3
• Anticonvulsants: Topiramate or divalproex sodium/sodium valproate (note: valproate is strictly contraindicated in pregnancy due to teratogenic risk) 2, 3, 4

Third-Line Preventive Options

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) with efficacy assessed after 3-6 months 2, 4
• OnabotulinumtoxinA with efficacy assessed after 6-9 months 2

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Treatment Goals and Follow-Up

The primary goals are to treat attacks rapidly and consistently, restore function, minimize back-up medications, optimize self-care, be cost-effective, and cause minimal adverse effects. 1

• Evaluate treatment response 2-3 months after initiation or change in treatment, then every 6-12 months 4
• Use headache calendars to track attack frequency, severity, and medication use 4
• Educate patients about medication overuse risks, frequency limits, and realistic expectations 3
• Identify and manage comorbid conditions including anxiety, depression, sleep disorders, and obesity 4

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Common Pitfalls to Avoid

Do not allow patients to increase frequency of acute medication use in response to treatment failure, as this creates a vicious cycle of medication-overuse headache. 2

Do not use opioids or butalbital-containing compounds routinely for acute migraine, as they have questionable efficacy and lead to dependency and rebound headaches. 2

Do not delay initiation of preventive therapy in patients requiring acute treatment more than twice weekly. 2, 3, 4

Do not assume failure of one triptan predicts failure of all triptans—try a different triptan before escalating to third-line agents. 2