What are the best management options for a patient experiencing migraines?

Migraine Management

Acute Treatment Strategy

For acute migraine attacks, start with NSAIDs (ibuprofen, aspirin, or diclofenac) plus an antiemetic if needed, escalating to triptans for moderate-to-severe attacks or when NSAIDs fail after three consecutive attempts. 1, 2

First-Line Acute Treatment

• NSAIDs have the strongest evidence and should be tried first for mild-to-moderate attacks, with aspirin-acetaminophen-caffeine combination as an alternative 1, 2
• Add an antiemetic (such as metoclopramide or prochlorperazine) if nausea or vomiting is present 2
• Acetaminophen alone is ineffective and should only be used if NSAIDs are contraindicated 2

Triptan Use for Moderate-to-Severe Attacks

• Triptans are most effective when taken early during an attack while headache is still mild 2
• All triptans have well-documented effectiveness, with sumatriptan (oral and subcutaneous), naratriptan, rizatriptan, and zolmitriptan having the strongest evidence 2, 3
• Individual response varies—if one triptan fails, try a different triptan before abandoning the class 2
• Use subcutaneous sumatriptan for rapid-onset severe attacks or when vomiting prevents oral medication 2

Critical Triptan Contraindications

• Triptans are absolutely contraindicated in patients with uncontrolled hypertension, coronary artery disease, hemiplegic or basilar migraine, history of stroke or TIA, Wolff-Parkinson-White syndrome, or Prinzmetal's angina 2, 3
• For triptan-naive patients with multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD), perform cardiovascular evaluation before prescribing 3
• Consider administering the first dose in a medically supervised setting with ECG monitoring for high-risk patients 3

Medication Overuse Prevention

• Limit triptans to fewer than 10 days per month and simple analgesics to fewer than 15 days per month to prevent medication overuse headache 2, 3, 4
• If medication overuse is suspected, initiate preventive therapy immediately 2

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Preventive Treatment Indications

Initiate preventive therapy when patients experience ≥2 attacks per month producing disability lasting ≥3 days per month, use acute medications more than twice weekly, have contraindications to acute treatments, or suffer from uncommon migraine variants. 1

First-Line Preventive Medications

• Beta-blockers (propranolol, metoprolol, atenolol, or bisoprolol), topiramate, or amitriptyline are first-line agents with documented high efficacy 1, 2
• Candesartan (16-32 mg oral daily) is an alternative first-line option, particularly useful in hypertensive patients 2
• For chronic migraine specifically, topiramate is the only oral medication proven effective in randomized placebo-controlled trials 1

Beta-Blocker Considerations

• Particularly useful for patients with comorbid hypertension 2
• Contraindicated in asthma, cardiac failure, Raynaud disease, atrioventricular block, and depression 2

Topiramate Considerations

• Dose: 50-100 mg oral daily 2
• Especially beneficial in obese patients 2
• Common adverse effects include cognitive inefficiency, paresthesia, fatigue, and weight loss 5
• Absolutely contraindicated in pregnancy and lactation 2

Second-Line Preventive Medications

• Amitriptyline (10-100 mg oral at night) or nortriptyline—particularly useful for patients with coexisting anxiety or depression 5, 2
• Flunarizine (5-10 mg oral once daily)—avoid in patients with Parkinsonism or depression 5, 2
• Valproic acid (600-1,500 mg oral once daily) for men only—absolutely contraindicated in women of childbearing potential due to teratogenicity 5, 2

Third-Line Preventive Medications for Refractory Cases

• CGRP monoclonal antibodies (erenumab 70 or 140 mg subcutaneous once monthly, fremanezumab 225 mg subcutaneous once monthly or 675 mg quarterly, galcanezumab, or eptinezumab 100 or 300 mg intravenous quarterly) for patients who fail multiple first- and second-line agents 5, 2
• OnabotulinumtoxinA (155-195 units to 31-39 sites every 12 weeks) for chronic migraine prophylaxis—the only FDA-approved therapy for this indication 5, 2

Treatment Assessment and Duration

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

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Non-Pharmacological Treatments

Behavioral and Lifestyle Interventions

• Cognitive-behavioral therapy, biofeedback, and relaxation training have good evidence for efficacy and should be integrated into comprehensive management 1
• Regular moderate-to-intense aerobic exercise for 40 minutes three times weekly is as effective as topiramate or relaxation therapy for migraine prevention 1
• Stress reduction techniques, regular sleep schedule, and maintaining adequate hydration are effective first-line interventions 5

Dietary Modifications

• Limit salt/sodium intake, avoid excessive caffeine, alcohol, and nicotine 5
• Eat well-balanced meals and avoid skipping meals 5
• Identify and avoid individual dietary triggers 5

Neuromodulatory Devices and Alternative Therapies

• Neuromodulatory devices can be considered as adjuncts or stand-alone treatment when medication is contraindicated 5, 2
• Acupuncture has some supporting evidence, though not superior to sham acupuncture 5

Supplements with Evidence

• Riboflavin (vitamin B2), coenzyme Q10, and magnesium citrate have favorable efficacy and safety profiles 1, 6, 7

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Special Populations and Situations

Menstrual-Related Migraine

• Consider perimenstrual prophylaxis with a long-acting NSAID (naproxen) or triptan (frovatriptan or naratriptan) for 5 days, beginning 2 days before expected menstruation 2
• Combined hormonal contraceptives are absolutely contraindicated if migraine with aura is present due to increased stroke risk 2

Comorbidity Management

• Treat comorbid conditions with medications that also benefit migraine when possible—such as amitriptyline for depression and migraine, or beta-blockers for hypertension and migraine 1
• Identify and manage modifiable risk factors including obesity, obstructive sleep apnea, psychiatric comorbidities (anxiety, depression), and stress 5

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Monitoring and Follow-Up

Tracking Treatment Response

• Use headache diaries to track attack frequency, severity, disability, and medication use 2
• Use validated disability tools such as the Migraine Disability Assessment Score (MIDAS) and HIT-6 to track treatment response 5
• Evaluate treatment response 2-3 months after initiation or change in treatment 2
• Key outcome measures include headache days per month, pain intensity, and migraine-related disability 2

Patient Education Principles

• Treatment adherence improves with simplified dosing schedules 5
• Set realistic expectations that efficacy is rarely observed immediately and may take several weeks to months 5
• Explain that failure of one preventive treatment does not predict failure of other drug classes 5

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Critical Pitfalls to Avoid

• Never use oral ergot alkaloids, opioids, or barbiturates due to questionable efficacy with considerable adverse effects and dependency risk 5, 2
• Do not abandon treatment prematurely—efficacy takes weeks to months to establish 5
• Avoid overuse of vestibular suppressant medications for long-term management 5
• Failure to recognize and manage comorbidities such as anxiety, depression, and sleep disturbances 5
• Do not use combined hormonal contraceptives in patients with migraine with aura 2