Migraine Headache Management
Acute Treatment Strategy
- The American College of Neurology recommends starting with NSAIDs or aspirin-acetaminophen-caffeine combination for mild-to-moderate attacks, escalating to triptans for moderate-to-severe attacks or when NSAIDs fail, and reserving gepants or lasmiditan for triptan failures or contraindications 1
Preventive Treatment Indications
- The American Academy of Neurology recommends initiating preventive therapy when patients experience ≥2 attacks per month producing disability lasting ≥3 days per month, use acute medications more than twice weekly, have contraindications to acute treatments, or suffer from uncommon migraine variants 1
First-Line Preventive Medications
- The American Headache Society recommends topiramate, beta-blockers, or amitriptyline as first-line agents for episodic migraine with documented high efficacy 3
- The American Academy of Neurology recommends topiramate for chronic migraine, as it is the only oral medication proven effective in randomized placebo-controlled trials specifically for this population 3
Non-Pharmacologic Treatments
- The American Headache Society recommends cognitive-behavioral therapy, biofeedback, and relaxation training as these have good evidence for efficacy and should be integrated into comprehensive management 3, 1
Exercise and Lifestyle
- The American College of Sports Medicine recommends regular moderate-to-intense aerobic exercise for 40 minutes three times weekly, which is as effective as topiramate or relaxation therapy for migraine prevention 3, 1
Comorbidity Management
- The American Academy of Neurology recommends treating comorbid conditions with medications that also benefit migraine when possible, such as amitriptyline for depression and migraine, or beta-blockers for hypertension and migraine 3, 2