Migraine Management

When migraine attacks occur infrequently (3 days or fewer per month) and are not associated with prolonged neurologic symptoms, abortive treatments are probably sufficient. However, daily prophylactic treatment should be considered if (1) headaches are usually disabling to the patient for 4 or more days per month, (2) the severity of the attacks, or even the dread of an attack, negatively impacts the patient’s ability to carry out normal activities of daily living between attacks, (3) headaches are associated with neurologic deficits that persist beyond the duration of the headache phase of the attack, (4) there is a history of migraine-associated cerebral infarction, or (5) the patient obtains only incomplete relief from all tolerated abortive treatments.

Acute migraine treatment mainstays are the nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen sodium or ketoprofen, and serotonin agonists, including the ergotamine derivative, dihydroergotamine (DHE) and the 5-hydroxtryptamine (5-HT) 1B and 5-HT 1D selective serotonin agonists, so-called “triptan” medications (sumatriptan, zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan, and frovatriptan). DHE is available in intravenous and intranasal formulations. The “triptans” are available in subcutaneous injectable, oral, and intranasal formulations. The preferred route of delivery may vary from patient to patient or may vary based the characteristics of a given attack.

For example, attacks that awaken the patient from sleep at a fully developed stage or that very rapidly escalate may require subcutaneous injection, Attacks that start while the patient is awake and gradually increase in intensity may respond well to an oral formulation. An NSAID combined with a triptan may provide better relief than a triptan alone.

The addition of an antiemetic, such as prochlorperazine or promethazine, may further increase the effectiveness of acute treatment. Although the use of nonspecific analgesic medications containing opiates or butalbital is sometimes necessary in patients with known contraindications for the use NSAIDS or serotonin agonists, caution is advised. The use of these medications more than 2 days per week may contribute to an increasing frequency and severity of headaches over time.

When prophylactic or preventive treatment is necessary, as noted above, several general principles should be remembered. To minimize side effects, prophylactic medications need to be started at a low dose and gradually increased over a period of a few weeks to a therapeutic target dose. Once the therapeutic dose is attained, the patient needs to be on the medication for at least 4 to 6 additional weeks to reliably assess effectiveness. Early discontinuation may deprive the patient of a potentially effective therapy. If drugs are not completely effective but are well-tolerated as monotherapies, then a combination of two agents, each from a different class, may be tried, despite the greater risk of side effects. Unfortunately, whether there is additional benefit to be gained from the use of combination therapy has not been examined thoroughly in a prospective evidence-based fashion. To be considered successful, the prophylactic treatment should reduce the number of headache–days per month by at least 50%.

Migraine preventive treatments come from at least six classes of medications, including beta-adrenergic blockers (atenolol, metoprolol, nadolol, propranolol, and timolol), tricyclic antidepressants (amitriptyline or nortriptyline), NSAIDs (naproxen sodium), calcium channel blockers (verapamil), anticonvulsants (divalproex sodium, topiramate, and gabapentin), and nutritional supplements (riboflavin, feverfew, and butterbur). Recently, the injection of botulinum toxin A has been shown to be an effective migraine prophylactic strategy in patients with chronic migraine headaches more than 15 days per month. Individual patients may find that one preventative agent is more effective than another. Unfortunately, at present, there is no method for drug selection other than trial and error. For some individuals, nonpharmacologic treatments, such as cognitive-behavioral therapy and biofeedback, play an important role in migraine management as well.

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