Headache Management

Definition and Diagnosis

• Medication overuse headache is defined as headache occurring on 15 or more days per month for at least 3 months in people with a pre-existing headache disorder that develops because of overuse of acute medication 1
• The diagnosis of hemiplegic migraines is based on the International Classification of Headache Disorders criteria, with key features including fully reversible motor weakness and at least one other aura symptom that develops gradually and lasts 5-60 minutes 2

Treatment Guidelines

• The American College of Physicians recommends using triptans on ≤10 days per month and NSAIDs on ≤15 days per month 1
• The American Academy of Neurology recommends avoiding opioids and butalbital-containing medications completely 1, 2
• Use NSAIDs (aspirin, ibuprofen, diclofenac) as first-line treatment for mild to moderate migraine 1, 2
• Add a triptan to an NSAID or acetaminophen for moderate to severe migraine 1
• Consider combination therapy with a triptan plus NSAID or acetaminophen to improve efficacy and potentially reduce the need for additional doses 1

• Effective treatments for acute migraine include:

  Medication	Recommended Dose
  Ibuprofen	400-600mg
  Naproxen sodium	500-550mg
  Sumatriptan	6mg subcutaneously for severe attacks or significant nausea/vomiting, or 50 mg orally
  Rizatriptan	10mg orally as a single dose for adolescents weighing ≥40kg, 50 mg for most patients, with a maximum daily dose of 200 mg in a 24-hour period

• Ditans (lasmiditan) or gepants (ubrogepant, rimegepant) are recommended as third-line treatment if triptans fail or are contraindicated, and CGRP Antagonists (Gepants) are considered for patients who don't respond to or cannot tolerate triptans and NSAIDs, according to the American College of Physicians 2, 3, 1

Preventive Treatment

• Prophylactic treatment should be initiated when a patient experiences ≥2 migraine attacks per month with disability lasting ≥3 days, or has uncommon migraine conditions such as hemiplegic migraine or migraine with prolonged aura, as recommended by the American College of Physicians 4
• Beta-blockers, such as propranolol, topiramate, or candesartan should be used as first-line preventive treatments for hemiplegic migraines, with acetaminophen and NSAIDs as first-line acute treatments, according to the International Classification of Headache Disorders criteria 2
• Beta-blockers, such as propranolol, are recommended as a first-line preventive option for migraine treatment, with a moderate strength of evidence, as recommended by the American Academy of Family Physicians 6
• The American College of Physicians strongly recommends CGRP monoclonal antibodies, such as erenumab, fremanezumab, or galcanezumab, for prevention of episodic or chronic migraine, with a strength of evidence level of high 4, 2, 3
• Other preventive treatment options include:

Lifestyle Modifications

• Pursue weight loss if overweight or obese 1
• Neglecting lifestyle factors, such as sleep, hydration, regular meals, and stress management, can worsen headache management 1
• Regular aerobic exercise, strength training, maintaining a regular sleep schedule, adequate hydration, identification and avoidance of triggers, and relaxation techniques or mindfulness are recommended as non-pharmacological approaches to headache management, as supported by the American Academy of Neurology, the American Headache Society, the American Heart Association, and the American College of Sports Medicine 4, 7, 2
• Relaxation training, thermal biofeedback combined with relaxation training, and cognitive-behavioral therapy are effective for migraine prevention and treatment, as recommended by the American Academy of Family Physicians, and acupuncture may be beneficial for patients who want to minimize medication use 6
• Cognitive Behavioral Therapy (CBT) is recommended for insomnia associated with headaches, reducing wakefulness by almost 1 hour per night, according to the National Comprehensive Cancer Network 8
• Sleep Hygiene Education, including regular morning or afternoon exercise, daytime exposure to bright light, and avoiding heavy meals, alcohol, and nicotine near bedtime, is recommended by the National Comprehensive Cancer Network 8

Medication Limitations and Monitoring

• The American Academy of Neurology and the American Headache Society recommend limitations for acute medications to prevent medication overuse headache:

  Medication	Recommended Limitation
  Sumatriptan	No more than 9 days per month
  OTC medications (e.g., ibuprofen, Excedrin Migraine)	No more than 14 days per month
  NSAIDs	No more than 15 days per month
  Ubrelvy	No more than 8 days per month

  4, 5, 2

• Educating patients on the importance of adhering to recommended medication limitations and monitoring for potential side effects, such as serotonin syndrome, is crucial for safe and effective migraine management, as recommended by the American Academy of Family Physicians and the American Headache Society 5, 2, 4

Treatment Evaluation and Referral

• Evaluate treatment response after 2-3 months of therapy, using headache calendars to document frequency, intensity, and disability, as recommended by the American Academy of Family Physicians and the American College of Physicians 2, 5
• If treatment is successful, continue for 6-12 months before attempting to taper to find minimum effective dose, and if treatment fails, check for medication overuse and compliance before switching to another option 2
• Referral indications include inadequate response to first-line treatments, presence of red flags, and need for preventive therapy 4, 3, 2