Migraine Management Guidelines

Acute Treatment of Migraine

• The American Academy of Family Physicians recommends NSAIDs as first-line treatment for mild to moderate migraine attacks, with consistent evidence supporting aspirin, ibuprofen, naproxen sodium, and the acetaminophen-aspirin-caffeine combination 1, 2
• Acetaminophen alone is ineffective for migraine treatment, according to the American Academy of Family Physicians 1
• Triptans, such as sumatriptan, should be used when NSAIDs are ineffective, as recommended by the American Academy of Family Physicians 1, 2
• The American Academy of Family Physicians advises that triptans are contraindicated in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or risk factors for heart disease 1
• Non-oral routes of administration, such as nasal sprays, should be used when nausea or vomiting are significant components of attacks, as suggested by the American Academy of Family Physicians 3, 2
• Antiemetic medications should be added when nausea is present, according to the American Academy of Family Physicians 3
• Combination therapy of a triptan with an NSAID may be more effective than either medication alone for patients with insufficient relief, as recommended by the American Academy of Family Physicians 2
• Limit acute treatments to no more than twice a week to prevent medication-overuse headaches, advises the American Academy of Family Physicians 1, 2
• Rebound headaches can occur with frequent use of opiates, triptans, ergotamine, and analgesics containing caffeine, isometheptene, or butalbital, according to the American Academy of Family Physicians 1

Preventive Treatment

• Preventive treatment should be considered for patients with two or more migraine attacks per month with disability lasting 3+ days per month, as recommended by the American Academy of Family Physicians 3, 4
• The American Academy of Family Physicians suggests that preventive treatment should be considered for patients with use of rescue medication more than twice per week 3, 4
• Beta blockers, such as propranolol, have good evidence for efficacy in migraine prevention, according to the American Academy of Family Physicians 3, 4
• Tricyclic antidepressants, such as amitriptyline, are effective for migraine prevention, as recommended by the American Academy of Family Physicians 3, 4
• Anticonvulsants, such as divalproex sodium, are effective preventive options, according to the American Academy of Family Physicians 3, 4
• Start with a low dose and titrate slowly upward until clinical benefits are achieved or side effects limit increases, advises the American Academy of Family Physicians 4
• Allow an adequate trial period of 2-3 months before determining efficacy, as recommended by the American Academy of Family Physicians 4
• Use headache diaries to track attack frequency, severity, duration, disability, treatment response, and adverse effects, according to the American Academy of Family Physicians 4

Special Considerations

• Opioids should be considered only if other medications cannot be used, after addressing risk of abuse and sedation concerns, as advised by the American Academy of Family Physicians 1
• Medication overuse headache can occur with frequent use of acute medications, according to the American Academy of Family Physicians 2, 4
• Detoxification may be necessary for patients with medication overuse headache, as recommended by the American Academy of Family Physicians 2
• Patients should be encouraged to identify and avoid migraine triggers, such as alcohol, caffeine, and stress, according to the American Academy of Family Physicians 1

Migraine Triggers and Dietary Considerations

Identifying and Managing Triggers

• The American Academy of Family Physicians recommends that patients identify and avoid personal migraine triggers, which may include certain foods or beverages 5
• Patients should be encouraged to track potential triggers using a headache diary to identify individual patterns, including all food and beverage consumption, timing, severity, and duration of migraine attacks, and other potential triggers like stress and sleep patterns 5

Clinical Approach to Migraine Prevention

• Food triggers represent just one of many potential migraine triggers, alongside stress, sleep disturbances, hormonal changes, and environmental factors 5