What are the follow-up management options for a patient with migraines?

Migraine Follow-Up Management

Establish a structured follow-up schedule evaluating treatment response at 2-3 months after initiating or changing therapy, then every 6-12 months once stable, using headache diaries to track attack frequency, severity, and medication use. 1

Monitoring Treatment Efficacy

Use validated disability assessment tools to objectively measure treatment response:

• Implement the Migraine Disability Assessment Score (MIDAS) and HIT-6 to quantify migraine-related disability 1
• Have patients maintain headache calendars documenting attack frequency, severity, duration, and all medication use 1
• Assess three primary outcomes: attack frequency, attack severity, and functional disability 1

Medication Overuse Surveillance

Monitor acute medication use rigorously to prevent medication overuse headache, which represents a major avoidable cause of disability:

• Limit triptans and combination analgesics to fewer than 10 days per month 1, 2
• Restrict simple analgesics and NSAIDs to fewer than 15 days per month 1
• Educate patients that overuse of acute medications (ergotamine, triptans, opioids for ≥10 days/month) leads to medication overuse headache, presenting as daily migraine-like headaches or marked increase in attack frequency 3, 2
• If medication overuse headache develops, detoxification with withdrawal of overused drugs and management of withdrawal symptoms (including transient headache worsening) becomes necessary 2

Preventive Therapy Assessment

For patients on preventive medications, evaluate efficacy after 2-3 months at therapeutic dose:

• Oral preventive medications (beta-blockers, topiramate, tricyclics) require 2-3 months assessment 1
• CGRP monoclonal antibodies need 3-6 months for efficacy determination 1
• OnabotulinumtoxinA requires 6-9 months assessment 1
• Consider pausing preventive therapy after 6-12 months of successful control to determine if continued treatment remains necessary 1

Comorbidity Management

Actively identify and manage conditions that worsen migraine outcomes:

• Screen for and treat anxiety and depression, which significantly impact migraine disability 1
• Evaluate for sleep disorders including obstructive sleep apnea 1
• Address obesity, as weight loss improves migraine outcomes 1
• Assess caffeine consumption patterns and medication overuse 1
• Monitor stress levels and provide stress management strategies 1

Treatment Escalation Algorithm

When patients experience ≥2 migraine days per month despite optimized acute treatment, implement preventive therapy using this stepped approach:

First-Line Preventive Options:

• Beta-blockers (propranolol, metoprolol, atenolol, bisoprolol) - particularly for patients with comorbid hypertension 1
• Topiramate 50-100 mg daily - especially beneficial in obese patients 1
• Candesartan - useful in hypertensive patients 1

Second-Line Options (if first-line fails):

• Amitriptyline or nortriptyline - particularly for patients with coexisting anxiety or depression 1
• Flunarizine 5-10 mg daily (avoid in patients with Parkinsonism or depression) 1
• Valproic acid - for men only; absolutely contraindicated in women of childbearing potential due to teratogenicity 1

Third-Line Options (for refractory cases):

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1
• OnabotulinumtoxinA 155-195 units every 12 weeks for chronic migraine 1

Acute Treatment Optimization

Reassess acute medication effectiveness at each follow-up:

• For mild-to-moderate attacks: NSAIDs (aspirin, ibuprofen, diclofenac) administered early in the headache phase 3, 1
• For moderate-to-severe attacks or those poorly responsive to NSAIDs: triptans as second-line 3, 1
• Consider combining triptans with NSAIDs to prevent headache recurrence 1
• For nausea/vomiting: use non-oral routes (nasal spray, injection, suppository) or add antiemetics 3

Critical Safety Monitoring

Screen for cardiovascular risk factors in triptan users:

• Perform cardiovascular evaluation before initiating triptans in patients with multiple risk factors (age, diabetes, hypertension, smoking, obesity, strong family history of CAD) 2
• Consider administering first triptan dose in medically supervised setting with post-dose ECG for high-risk patients 2
• Monitor blood pressure in all patients on triptans, as hypertensive crisis can occur 2
• Discontinue triptans immediately if chest pain, arrhythmias, or cerebrovascular symptoms develop 2

Red Flags Requiring Urgent Re-evaluation

Immediately reassess patients presenting with:

• New-onset migraine after age 50 (raises suspicion of secondary causes) 1
• Change in headache pattern or characteristics 1
• Neurological symptoms beyond typical aura 2
• Persistent aura lasting >72 hours 1
• Seizures during attacks 4
• Altered consciousness during attacks 4

Patient Education Reinforcement

At each follow-up visit, emphasize:

• Treatment adherence improves with simplified dosing schedules 1
• Efficacy rarely occurs immediately and may require several weeks to months 1
• Failure of one preventive medication does not predict failure of other drug classes 1
• Lifestyle modifications (regular sleep, avoiding triggers, stress management, regular exercise) remain foundational 1

Common Pitfalls to Avoid

• Never abandon preventive treatment prematurely - efficacy takes weeks to months to establish 1
• Avoid prescribing opioids or barbiturates - they have questionable efficacy with considerable adverse effects and dependency risk 3, 1
• Do not use ergot alkaloids - they are poorly effective and potentially toxic 4
• Never overlook medication overuse - this represents the major avoidable cause of headache disability in developed countries 5