Management of Migraine

Acute Treatment

• The American Academy of Neurology recommends starting with NSAIDs (ibuprofen, aspirin, or diclofenac) plus an antiemetic if needed for acute migraine attacks in a 25-year-old patient, and escalating to triptans if three consecutive attacks fail to respond adequately to NSAIDs 1
• The American Family Physician suggests that NSAIDs have the strongest evidence for efficacy and should be tried first in most patients 2, 3
• The American Academy of Neurology states that paracetamol (acetaminophen) alone is ineffective and should only be used if NSAIDs are contraindicated 1
• The American Academy of Neurology recommends adding an antiemetic if nausea or vomiting is present 1
• The American Family Physician notes that all triptans have well-documented effectiveness, with good evidence for sumatriptan (oral and subcutaneous), naratriptan, rizatriptan, and zolmitriptan 2, 1
• The American Academy of Neurology advises that triptans are most effective when taken early during an attack while headache is still mild 1
• The American Academy of Neurology recommends trying different triptans as individual response varies if one triptan fails 1
• The American Academy of Neurology suggests using subcutaneous sumatriptan for rapid-onset severe attacks or when vomiting prevents oral medication 1
• The American Family Physician warns that triptans should not be used in patients with uncontrolled hypertension, coronary artery disease, hemiplegic or basilar migraine, or cardiovascular risk factors without proper evaluation 2

Preventive Treatment

• The American Academy of Neurology recommends considering preventive therapy if the patient experiences migraine-related disability on ≥2 days per month despite optimized acute treatment 4
• The American Academy of Neurology suggests choosing from beta-blockers, topiramate, or candesartan as first-line preventive medications 5, 4
• The American Academy of Neurology notes that beta-blockers, such as propranolol, metoprolol, atenolol, or bisoprolol, can be used as first-line preventive medications, but are contraindicated in asthma, cardiac failure, Raynaud disease, atrioventricular block, and depression 5
• The American Academy of Neurology recommends using topiramate 50-100 mg oral daily as a first-line preventive medication, but notes that it is absolutely contraindicated in pregnancy and lactation 5
• The American Academy of Neurology suggests using candesartan 16-32 mg oral daily as a first-line preventive medication 5
• The American Academy of Neurology recommends considering second-line preventive medications, such as amitriptyline, flunarizine, or sodium valproate, if first-line agents fail or are contraindicated 5, 4
• The American Academy of Neurology notes that sodium valproate is absolutely contraindicated in women of childbearing potential due to teratogenicity 5, 4
• The American Academy of Neurology suggests using CGRP monoclonal antibodies, such as erenumab, fremanezumab, galcanezumab, or eptinezumab, as third-line preventive medications for patients who fail multiple first- and second-line agents 5
• The American Academy of Neurology recommends using onabotulinumtoxinA 155-195 units to 31-39 sites every 12 weeks as a third-line preventive medication for chronic migraine prophylaxis 5

Special Considerations

• The American Academy of Neurology recommends considering perimenstrual prophylaxis with a long-acting NSAID (naproxen) or triptan (frovatriptan or naratriptan) for 5 days, beginning 2 days before expected menstruation, for female patients with menstrual-related migraines 5
• The American Academy of Neurology warns that combined hormonal contraceptives are absolutely contraindicated if migraine with aura is present due to increased stroke risk 5

Medication Overuse Prevention

• The American Family Physician warns that medication overuse headache can occur if acute treatment is used more than twice weekly (or <10 days/month for triptans, <15 days/month for simple analgesics) 3, 6, 8
• The American Family Physician recommends initiating preventive therapy immediately if medication overuse is suspected or at risk 3

Monitoring and Follow-Up

• The American Academy of Neurology recommends evaluating treatment response 2-3 months after initiation or change in treatment 9
• The American Academy of Neurology suggests using a headache diary to track attack frequency, severity, disability, and medication use 9, 3
• The American Academy of Neurology notes that key outcome measures include headache days per month, pain intensity, and migraine-related disability 9

Non-Pharmacological Adjuncts

• The American Academy of Neurology recommends considering neuromodulatory devices, biobehavioral therapy, or acupuncture as additions to medication or when medications are contraindicated 4