What are the best management strategies for a patient experiencing migraine episodes?

Management of Migraine

Acute Treatment Strategy

For mild to moderate migraine attacks, start with NSAIDs (oral ibuprofen, aspirin, or diclofenac potassium) or combination analgesics containing aspirin, acetaminophen, and caffeine, administered as early as possible during an attack to maximize efficacy. 1, 2

Stratified Approach Based on Attack Severity

Mild to Moderate Attacks:

• First-line: Oral NSAIDs (ibuprofen, aspirin, diclofenac potassium) 1, 2
• Alternative: Combination analgesics containing aspirin + acetaminophen + caffeine 1
• Note: Acetaminophen alone is NOT recommended for migraine and has not been shown to be beneficial 1
• Administer medication at the earliest signs of headache to improve efficacy 1, 3

Moderate to Severe Attacks or Poor Response to NSAIDs:

• Migraine-specific agents (triptans): Sumatriptan, rizatriptan, zolmitriptan, naratriptan 1, 4
• Triptans are most effective when taken early in an attack while pain is still mild 2, 4
• If one triptan is ineffective, try another as individual responses vary 2
• For rapid onset or severe attacks with vomiting, use subcutaneous sumatriptan 2
• Alternative: Dihydroergotamine (DHE) 1

Migraine with Nausea/Vomiting:

• Use non-oral route of administration 1
• Add antiemetic prokinetics: metoclopramide or domperidone 1, 2
• Prochlorperazine can effectively relieve both headache pain and nausea 1

Severe Migraine Not Responding to Other Treatments:

• Parenteral ketorolac (Toradol) for severe attacks 1
• Consider self-administered rescue medication for home use 1

Critical Medications to AVOID

Absolutely avoid or severely limit:

• Opioids (meperidine, butorphanol): Risk of dependency, rebound headaches, and loss of efficacy 1, 2
• Barbiturates/butalbital-containing compounds: Risk of dependency and medication overuse headache 1, 2
• Oral ergot alkaloids: Poor efficacy and potentially toxic 2

Medication Overuse Prevention

Strictly limit acute medication use to prevent medication overuse headache (MOH):

• Simple analgesics/NSAIDs: <15 days per month 5, 4
• Triptans: <10 days per month 5, 4
• Overall acute treatment: No more than twice weekly 1, 6
• Overuse of acute medications (≥10 days/month) leads to medication overuse headache, presenting as daily headaches or marked increase in migraine frequency 4

Preventive Therapy

Consider preventive therapy for patients with migraine affecting quality of life on ≥2 days per month despite optimized acute treatment, or when acute medication is used more than twice weekly. 1, 5, 2

Indications for Preventive Therapy

• Migraine significantly interfering with daily routine despite acute treatment 1, 7
• Failure, contraindication, or troublesome side effects from acute medications 1, 7
• Overuse of acute medications (>2 times per week) 1, 6, 2
• Very frequent headaches (>2 per week) 7
• Special circumstances: hemiplegic migraine, prolonged aura, migrainous infarction 1

First-Line Preventive Medications

Beta-blockers (propranolol, metoprolol, atenolol, bisoprolol):

• Particularly useful in patients with comorbid hypertension 5, 7, 8
• High documented efficacy with mild to moderate adverse events 7

Topiramate (50-100 mg oral daily):

• Especially beneficial in obese patients due to weight loss effect 5, 6, 2
• Common adverse effects include cognitive inefficiency, paresthesia, fatigue 5

Candesartan (angiotensin receptor blocker):

• First-line option, particularly useful in hypertensive patients 5, 7

Amitriptyline:

• High documented efficacy 7, 8
• Particularly useful for patients with coexisting anxiety, depression, or sleep disorders 5, 2

Second-Line Preventive Medications

• Flunarizine (5-10 mg oral once daily): Avoid in patients with Parkinsonism or depression 5
• Nortriptyline: Alternative tricyclic antidepressant 5
• Valproic acid (600-1,500 mg oral daily): Option for men only; absolutely contraindicated in women of childbearing potential due to teratogenicity 5, 2

Third-Line Preventive Medications

For Chronic Migraine or Refractory Cases:

• CGRP monoclonal antibodies: Erenumab, fremanezumab, galcanezumab, eptinezumab 5, 2, 8

  • Assess efficacy after 3-6 months 5, 2

• OnabotulinumtoxinA (155-195 units to 31-39 sites every 12 weeks):

  • Only FDA-approved therapy for chronic migraine prophylaxis 5, 2
  • Assess efficacy after 6-9 months 5, 2

Treatment Assessment Timeline

• Oral preventive medications: Assess efficacy after 2-3 months at therapeutic dose 5, 2, 7
• CGRP monoclonal antibodies: Assess after 3-6 months 5, 2
• OnabotulinumtoxinA: Assess after 6-9 months 5, 2
• Consider pausing treatment after 6-12 months of successful control to determine if preventive therapy can be stopped 5

Non-Pharmacological Management

Lifestyle Modifications (Essential for All Patients):

• Regular sleep schedule: Poor sleep quality is a major predisposing factor 5, 6
• Regular exercise: 40 minutes three times weekly is as effective as topiramate or relaxation therapy 6, 8
• Dietary measures: Eat regularly, maintain adequate hydration, limit excessive caffeine, alcohol, and nicotine 5, 6
• Weight loss: Critical in obese patients as obesity is the single most important modifiable risk factor for chronic migraine 6
• Stress management: Cognitive-behavioral therapy, biofeedback, and relaxation techniques 5, 6, 8

Nutraceuticals with Evidence:

• Magnesium citrate 8
• Riboflavin 7, 8
• Coenzyme Q10 8

Management of Comorbidities

Identify and treat comorbid conditions as their management directly improves migraine outcomes:

• Depression and anxiety: Consider amitriptyline or nortriptyline as preventive therapy 5, 2
• Obesity: Prioritize topiramate due to weight loss effect 5, 6, 2
• Sleep disorders: Address with sleep hygiene and consider amitriptyline 5, 6, 2
• Hypertension: Use beta-blockers or candesartan 5

Critical Pitfalls to Avoid

• Do not overemphasize trigger avoidance: This can lead to unnecessary avoidance behavior that damages quality of life 6
• Do not abandon treatment prematurely: Efficacy takes weeks to months to establish 5
• Do not use opioids or barbiturates routinely: Questionable efficacy with considerable adverse effects and dependency risk 1, 5, 2
• Monitor for medication overuse headache: Requires withdrawal of overused medications before initiating preventive therapy 6, 2, 4
• Perform cardiovascular evaluation in triptan-naive patients with multiple cardiovascular risk factors before prescribing triptans 4
• Contraindications to triptans: Coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, history of stroke/TIA, Wolff-Parkinson-White syndrome 4

Treatment Selection Algorithm

Start with patient stratification:

1. Assess attack frequency, severity, and disability level
2. Evaluate response to previous treatments
3. Identify comorbidities and contraindications
4. Consider patient preferences and cost

For acute treatment:

• Mild-moderate attacks → NSAIDs
• Moderate-severe or NSAID failures → Triptans
• With nausea/vomiting → Non-oral route + antiemetics

For preventive therapy:

• If ≥2 disabling days/month or acute medication overuse → Initiate prevention
• Select based on comorbidities: hypertension (beta-blockers/candesartan), obesity (topiramate), depression/anxiety (amitriptyline)
• If first-line fails after 2-3 months → Try alternative first-line agent
• If multiple first-line failures → Consider second-line agents
• If chronic migraine or refractory → CGRP antibodies or onabotulinumtoxinA