Management of Daily Migraines

Current Treatment Assessment

• The American College of Physicians recommends that Esgic (butalbital, acetaminophen, caffeine) as a PRN medication is concerning because butalbital-containing compounds can lead to medication-overuse headache and rebound headaches when used frequently 1, 2
• Daily migraines indicate treatment failure and warrant immediate adjustment of both preventive and acute treatment strategies 3

Next Steps for Management

• The American Academy of Family Physicians recommends limiting acute therapy to no more than twice weekly to prevent medication-overuse headache 1, 3
• The American College of Physicians recommends avoiding opioids for migraine management due to risk of dependence and medication-overuse headache 1, 2

Considerations for Preventive Therapy

• The American Academy of Neurology recommends first-line preventive options with documented high efficacy, including beta-blockers (propranolol, timolol) 2
• The American Academy of Family Physicians recommends considering non-pharmacological approaches such as relaxation techniques, biofeedback, and stress management as adjunctive therapy, and identifying and addressing potential migraine triggers (alcohol, caffeine, certain foods, stress, fatigue, etc.) 3, 4

Cautions

• The American College of Physicians recommends monitoring for side effects of increased verapamil dosing, including constipation, dizziness, and potential cardiac effects, and being vigilant for signs of medication overuse, which can perpetuate daily headaches 1, 2, 3