Migraine Management

Assessment and Diagnosis

The American Academy of Neurology recommends a stepped care strategy for migraine management, starting with NSAIDs for mild to moderate attacks, progressing to triptans for moderate to severe attacks, and implementing preventive therapy for patients adversely affected on ≥2 days per month despite optimized acute treatment 1, 2, 3
Migraine is characterized by recurrent episodes of headache, typically unilateral, pulsatile, moderate to severe intensity, aggravated by physical activity and associated with nausea, vomiting, photophobia, and phonophobia 4, 5
Be particularly vigilant in patients with apparent late-onset migraine (after age 50), as this should raise suspicion of an underlying cause 1
Monitor for medication overuse headache in patients using acute medications frequently (≥10 days/month for triptans or ≥15 days/month for NSAIDs) 2, 4

The American Headache Society recommends NSAIDs as first-line treatment for mild to moderate migraine attacks, with triptans as second-line treatment for moderate to severe attacks 2, 4, 3
Use acetylsalicylic acid, ibuprofen, or diclofenac potassium for mild to moderate attacks 3
Administer early in the headache phase for maximum effectiveness 3
Consider combining triptans with NSAIDs to prevent relapse 3

The American Academy of Neurology recommends preventive therapy for patients with frequent migraine attacks (≥2 days per month) despite optimized acute treatment 6, 7, 4, 3
Beta-blockers (atenolol, bisoprolol, metoprolol, propranolol) and topiramate are first-line options for preventive therapy 7, 6
CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) and onabotulinumtoxinA are third-line options for preventive therapy 6, 7

The American Academy of Neurology recommends considering comorbidities and potential drug interactions in older patients 7, 6
In children and adolescents, use ibuprofen as first-line medication at appropriate weight-based dosing, and consider propranolol, amitriptyline, or topiramate for prevention 1, 7, 3
For women with menstrual migraine, consider short-term prevention with NSAIDs or triptans, and combined hormonal contraceptives may benefit women with pure menstrual migraine without aura 1

Educate patients about medication overuse headache risk with frequent use of acute medications 6
Identify and manage comorbid conditions including anxiety, depression, sleep disorders, and obesity 6, 4
Adjust treatments considering potential interactions between medication side effects and patient comorbidities 6

Evaluate treatment response 2-3 months after initiation or change in treatment, then every 6-12 months 1
Use headache calendars to track attack frequency, severity, and medication use 1, 5
Assess effectiveness using attack frequency, attack severity, and migraine-related disability 1