Migraine and Headache Management

Clinical Presentation and Diagnosis

• The American Academy of Family Physicians notes that migraine with aura is characterized by visual flashes before headache onset 2
• Neck pain may suggest a mixed migraine and tension-type headache, guiding medication selection 1

Treatment Options

• The American College of Physicians recommends amitriptyline (30-150 mg/day) as superior to propranolol for patients with mixed migraine and tension-type headache 1
• Amitriptyline is the only tricyclic antidepressant with consistent evidence supporting efficacy for headache prevention 1
• Propranolol (80-240 mg/day) is superior for pure migraine without tension-type features, but may worsen depression 1, 3

Preventive Therapy

• The American Academy of Family Physicians and the American College of Physicians-American Society of Internal Medicine suggest that patients with headaches occurring most days (≥2 attacks per month with significant disability) are candidates for preventive therapy 5
• The Annals of Internal Medicine recommends considering preventive therapy for patients likely overusing acute medications 2, 5

Medication Management

• The American College of Physicians recommends starting amitriptyline 10-25 mg at bedtime, gradually titrating to 30-150 mg/day as tolerated 1
• Allow 2-3 months for full therapeutic benefit before declaring treatment failure 1, 3

Monitoring and Follow-up

• The American Academy of Family Physicians suggests encouraging patients to keep a headache diary to track frequency, severity, duration, disability, and medication use 2, 5
• Reassess patients after an adequate trial period (2-3 months at therapeutic dose) 1