Migraine Treatment and Prevention

Introduction to Migraine Management

The American College of Physicians recommends nonsteroidal anti-inflammatory drugs (NSAIDs) as the first-line therapy for acute migraine attacks, while preventive therapy should be considered for patients with two or more attacks per month causing significant disability 1, 2

Common triggers of migraine attacks include alcohol, caffeine, foods containing tyramine or nitrates, stress, fatigue, perfumes, fumes, glare, and flickering lights 3
Hormonal fluctuations, particularly in women, can trigger migraine attacks 4

The American Academy of Family Physicians recommends NSAIDs as first-line treatment for mild to moderate migraine attacks 5, 1, 2
Most consistent evidence exists for aspirin, ibuprofen, naproxen sodium, and the acetaminophen-aspirin-caffeine combination 5, 1
Acetaminophen alone is ineffective for migraine 5, 1
Migraine-specific agents (triptans, dihydroergotamine [DHE]) should be used in patients whose migraine attacks do not respond to NSAIDs 5, 1, 2
Effective triptans include oral naratriptan, rizatriptan, zolmitriptan, and oral/subcutaneous sumatriptan 5, 1
Triptans are contraindicated in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or those at risk for heart disease 5

The American College of Physicians recommends preventive therapy for patients with two or more migraine attacks per month with disability lasting 3 or more days per month 5, 1, 4
The VA/DoD guidelines strongly recommend candesartan or telmisartan for episodic migraine, and erenumab, fremanezumab, or galcanezumab for episodic or chronic migraine 2
Other effective preventive medications include beta blockers, tricyclic antidepressants, anticonvulsants, and angiotensin-converting enzyme inhibitors 5, 1, 2, 4
Supplements such as oral magnesium may also be effective in preventing migraine 2

The American Academy of Family Physicians recommends starting with a low dose and titrating slowly upward until clinical benefits are achieved or side effects limit further increases 1, 4
An adequate trial period of 2-3 months should be allowed before determining efficacy 1, 4
Headache diaries should be used to track attack frequency, severity, duration, resulting disability, response to treatment, and adverse effects 4

Medication overuse headache can be prevented by limiting use of acute treatments to no more than twice a week 5, 3
OnabotulinumtoxinA is recommended for prevention of chronic migraine but carries risks including problems with swallowing, speaking, or breathing 2

Daily headache diaries should be used to track progress and assess treatment effectiveness 3, 4
Patients should be educated about migraine as a disease and principles of management, and encouraged to identify personal triggers to avoid future attacks 4, 3