Acute and Preventive Treatment of Migraine

Introduction to Migraine Management

The American Academy of Neurology recommends starting with NSAIDs (aspirin, ibuprofen, or potassium diclofenac) for mild to moderate migraine attacks, and using triptans or combination therapy from the start for moderate to severe attacks 1, 2

For mild to moderate migraine attacks, NSAIDs such as aspirin, ibuprofen, and diclofenac potassium are effective options 1, 2
The combination of aspirin, paracetamol, and caffeine is strongly recommended as first-line therapy for mild to moderate migraine, with a number needed to treat of 9 for pain freedom at 2 hours 1
Triptans should be offered when over-the-counter analgesics provide inadequate relief 1

Consider preventive therapy for patients with two or more attacks per month that produce disability for 3+ days per month, contraindication or failure of acute treatments, or use of acute medication more than twice a week 1
The American Headache Society recommends topiramate as a first-line option due to its lower cost, but requires discussion of teratogenic effects with patients of childbearing age 1, 2
Propranolol is an effective option for prevention 3, 1

Cognitive-behavioral therapy, biofeedback, and relaxation training should be offered to all patients as part of comprehensive management, as they have good evidence of efficacy 1
Regular moderate to intense aerobic exercise (40 minutes, three times a week) is as effective as some preventive medications 1

Take a detailed history and make a specific diagnosis of headache 3
It is essential to rule out secondary causes of headache through detailed history and physical examination, especially in patients with red flags such as sudden onset, fever, neck stiffness, or focal neurological deficit 2
Educate patients and families about lifestyle factors, migraine triggers, and avoidance of overuse of acute medication 3
The long-term management of migraine should be the responsibility of primary care 2
Recommend the use of headache diaries to monitor frequency, intensity, and response to treatment 2