From the Guidelines
Clinical practice guidelines for migraines recommend a comprehensive approach to diagnosis and treatment, prioritizing the use of ditan lasmiditan for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to all other pharmacologic treatments. For acute migraine attacks, first-line medications include NSAIDs and triptans, which should be taken early in the attack for maximum effectiveness 1. The guidelines also emphasize the importance of counseling patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy to improve efficacy. Additionally, patients should be aware of medication overuse headache, which is a potential complication of migraine treatment, and lifestyle modifications such as staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, engaging in regular physical activity, managing stress with relaxation techniques or mindfulness practices, and pursuing weight loss for those who are overweight or obese are essential components of migraine management 1.
Key considerations in migraine management include:
- Using a nonoral triptan and an antiemetic in people having severe nausea or vomiting 1
- Discussing the adverse effects of pharmacologic treatments during pregnancy and lactation with patients of childbearing potential 1
- Considering the addition of preventive medications if the episodic migraine occurs frequently or treatment does not provide an adequate response 1
- Highlighting the importance of lifestyle modifications and exploring modifiable migraine triggers or contributing factors during a detailed history 1
In terms of preventive therapy, guidelines recommend considering prophylactic therapy when migraines occur more than 4 days per month or significantly impact quality of life, with first-line preventive medications including beta-blockers, anticonvulsants, and certain antidepressants 2. However, the most recent and highest quality study 1 prioritizes the use of ditan lasmiditan for moderate to severe acute episodic migraine headache, and this should be considered in clinical practice. Overall, the goal of migraine management is to reduce headache frequency, severity, and associated disability while minimizing medication side effects and avoiding medication overuse headaches.
From the FDA Drug Label
The averages displayed are based on pooled data from 4 placebo-controlled, outpatient trials providing evidence of efficacy (Studies 1, 2, 3, and 4). Patients taking additional treatment or not achieving headache response prior to 2 hours were censored at 2 hours For patients with migraine-associated photophobia, phonophobia, and nausea at baseline, there was a decreased incidence of these symptoms following administration of rizatriptan benzoate compared to placebo Efficacy was unaffected by the presence of aura; by the gender, or age of the patient; or by concomitant use of common migraine prophylactic drugs (e.g., beta-blockers, calcium channel blockers, tricyclic antidepressants) or oral contraceptives.
The clinical practice guidelines for migraines are not directly addressed in the provided drug label. However, the label does provide information on the efficacy of rizatriptan benzoate in treating migraines, including:
- The estimated probability of achieving an initial headache response within 2 hours following treatment
- The decreased incidence of migraine-associated symptoms (photophobia, phonophobia, and nausea) following administration of rizatriptan benzoate
- The lack of effect of certain factors (aura, gender, age, concomitant use of common migraine prophylactic drugs or oral contraceptives) on efficacy 3
From the Research
Clinical Practice Guidelines for Migraines
- Migraine management includes avoidance of trigger factors, lifestyle modifications, non-pharmacological therapies, and medications 4
- Pharmacological treatment is traditionally divided into acute or symptomatic treatment, and preventive treatment or prophylaxis 4
- Patients with severe and/or frequent migraines require long-term preventive therapy, which may include anti-migraine compounds with potential adverse events or contraindications 4
Non-Pharmacological Approaches
- Non-pharmacological recommendations for managing migraine disorder include identifying and managing trigger factors, such as environmental factors, sleep pattern changes, diet, physical activity, stress and anxiety, and hormonal changes 5
- Weight control, management of migraine comorbidities, lifestyle modification, behavioral treatment, and biofeedback are also recommended as part of migraine management 5
- Using headache diaries and improving patients' knowledge about the disease can also be helpful in managing migraines 5
Acute Migraine Treatment
- Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine 6
- Migraine-specific treatments, such as triptans, can eliminate pain in 20% to 30% of patients by 2 hours, but are accompanied by adverse effects 6
- Gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, can also eliminate headache symptoms for 2 hours in 20% of patients, but have adverse effects of nausea and dry mouth 6
Preventive Treatments
- Preventive treatments for migraines include antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, which can reduce migraine by 1 to 3 days per month relative to placebo 6
- The American Headache Society recommends that all triptans, acetaminophen, and non-steroid anti-inflammation drugs be considered effective for acute migraine treatment 7
Medication Guidelines
- The Taiwan Headache Society published treatment guidelines for acute migraine attack, which recommend migraine-specific triptans and migraine-nonspecific nonsteroidal antiinflammatory drugs as first-line medications for acute migraine attacks 7
- The guidelines also recommend that the administration of acute medications follow the concept of "stratified care", with oral NSAIDs as the first choice for mild to moderate migraine attacks, and oral or nasal spray triptans and ergotamine/caffeine compounds for moderate to severe attacks 7