Management of Headache According to Malaysian Guidelines
I cannot provide specific recommendations from the Malaysian Ministry of Health (MSN) 2021 headache management guidelines because no Malaysian MSN 2021 guideline document was included in the provided evidence. 1
Available Evidence and Alternative Approach
The only Malaysian evidence available is a 1996 community prevalence study showing migraine affects 9.0% and tension-type headache affects 26.5% of the Malaysian population, with no significant differences among racial groups or urban versus rural populations. 1
In the absence of the specific Malaysian MSN 2021 guideline, I will provide evidence-based headache management recommendations from the highest-quality international guidelines (2021 Nature Reviews Neurology consensus statement) that can serve as a framework until the Malaysian guideline is accessed. 2
Diagnosis of Primary Headache Disorders
Migraine Without Aura
Diagnose when a patient has at least five attacks fulfilling all of the following: 2
- Headache lasting 4–72 hours when untreated
- At least two of these characteristics:
- Unilateral location
- Pulsating quality
- Moderate or severe intensity
- Aggravation by routine physical activity
- At least one accompanying symptom:
- Nausea and/or vomiting
- Photophobia and phonophobia
- Not better explained by another diagnosis 2
Migraine With Aura
Diagnose when a patient has at least two attacks with fully reversible aura symptoms (visual, sensory, speech/language, motor, brainstem, or retinal) that spread gradually over ≥5 minutes, last 5–60 minutes, and are accompanied by or followed by headache within 60 minutes. 2
Chronic Migraine
Diagnose when headache occurs on ≥15 days per month for >3 months, with migraine features present on ≥8 days per month. 2
Medication-Overuse Headache (MOH)
Diagnose when headache occurs on ≥15 days per month in a patient with pre-existing headache disorder who has been regularly overusing acute medication for >3 months: 2
- Non-opioid analgesics on ≥15 days/month
- Triptans, ergots, or combination analgesics on ≥10 days/month 2
Acute Treatment Algorithm
Step 1: Mild to Moderate Migraine
Start with NSAIDs or acetaminophen: 3, 4
Add caffeine-containing combination (aspirin + acetaminophen + caffeine) if NSAIDs alone are insufficient. 3
Step 2: Moderate to Severe Migraine or NSAID Failure
- Oral triptans: sumatriptan 50–100 mg, rizatriptan 10 mg, naratriptan, or zolmitriptan 3
- Subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours) with 15-minute onset 3
- Intranasal sumatriptan 5–20 mg when nausea/vomiting is prominent 3
Combination therapy (triptan + NSAID) is superior to either agent alone. 3
Step 3: Parenteral Therapy for Severe Attacks
When oral routes fail or significant nausea/vomiting is present: 3
- Metoclopramide 10 mg IV (provides direct analgesic effect beyond antiemetic properties) 3
- Ketorolac 30 mg IV (rapid onset, 6-hour duration, minimal rebound risk) 3
- Prochlorperazine 10 mg IV (comparable efficacy to metoclopramide) 3
- Dihydroergotamine (DHE) intranasal or IV as alternative 3
Optimal IV "cocktail": Metoclopramide 10 mg + Ketorolac 30 mg 3
Critical Frequency Limitation
Limit ALL acute medications to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache. 2, 3, 4
Medications to Avoid
- Opioids (hydromorphone, oxycodone, codeine) – limited efficacy, high dependency risk, cause medication-overuse headache 3, 4
- Butalbital-containing compounds – high risk of medication-overuse headache 3
- Ergot alkaloids (Cafergot) – inferior to triptans, substantial cardiovascular risks 3
When to Initiate Preventive Therapy
Start preventive treatment when: 2, 3
- ≥2 attacks per month causing disability lasting ≥3 days
- Acute medication use >2 days per week
- Contraindication to or failure of acute treatments
- Patient preference for prevention 2, 3
First-Line Preventive Medications
- Propranolol 80–240 mg/day 3
- Timolol 20–30 mg/day 3
- Topiramate (dose titration required) 3
- Amitriptyline 30–150 mg/day (especially with comorbid depression or tension-type headache) 3
Third-Line for Chronic Migraine
- OnabotulinumtoxinA (Botox) 155–195 U every 12 weeks – only FDA-approved preventive specifically for chronic migraine 3
- CGRP monoclonal antibodies when oral preventives fail 3
Management of Medication-Overuse Headache
When acute medications are used ≥10 days/month (triptans) or ≥15 days/month (NSAIDs): 2, 5
- Abruptly withdraw all overused medications (except opioids/barbiturates, which require slow taper) 2, 5
- Warn patient of 2–10 days of worsening headache during withdrawal 2
- Initiate preventive therapy immediately 2, 5
- Do not substitute another acute medication during withdrawal 2
- Reassess after 2–4 weeks when baseline headache pattern emerges 2
Red Flags Requiring Urgent Evaluation
Perform neuroimaging (MRI preferred) when: 2, 4, 6
- Thunderclap headache (sudden, severe onset)
- Atypical aura or new neurological deficits
- Recent head trauma
- Fever with headache
- Impaired memory or consciousness
- Age >50 years with new-onset headache
- Progressive worsening pattern 2, 4, 6
Follow-Up and Treatment Evaluation
- Evaluate treatment response 2–3 months after initiation or change 2
- Use headache diaries to track frequency, severity, and medication use 2
- Reassess regularly every 6–12 months thereafter 2
- Refer to specialist when diagnosis is uncertain, all treatments fail, or complications arise 2
To obtain the specific Malaysian MSN 2021 guideline recommendations, please access the official Ministry of Health Malaysia clinical practice guideline document directly.