Devin Pinaroc, FNP-C

Takeaways

• Treatment of migraine episodes is addressed in a stratified or “step” approach, choosing an initial medication based on intensity or starting with the simplest treatment and moving up, respectively. 
• Abortive therapies should not be used more than 10 days per month (or less than 15 days per month for aspirin, acetaminophen, and NSAIDS) 
• First line treatment is NSAIDs and/or acetaminophen for mild to moderate episodes. Triptans are first line treatment for moderate to severe episodes. 
• Adjunct medications and therapies are often given to address symptoms associated with migraines, like providing antibiotics for migraine – associated nausea or steroids to prevent recurrence. 

 

Migraine is a primary headache disorder characterized by recurrent debilitating, severe headaches associated with nausea, photophobia, and/or phonophobia (Smith, 2021). The POUND mnemonic summarizes the clinical features (Mayans & Walling, 2018).  

 

(P)ulsatile quality of headache

(O)ne-day duration of headache

(U)nilateral headache

N)ausa/vomitting

(D)isabilty intensity of headache 

 

Treatments are categorized between acute “abortive” therapy – addressing an active migraine – and preventative therapy –  stopping migraines before they happen. Although prevention is the goal, taking a preventative medication every day may not be feasible or unneeded for those with infrequent migraines. 

 

Treatment Principles 

Overall, abortive medications work best when given early in the course of the headache and in large initial doses rather than in small repetitive doses (Smith, 2021). The variety of abortive medications allow individualized treatment plans that often consist of multiple medications, so follow up and treatment adjustment are key in managing acute migraines (Mayans & Walling, 2018).  In addition to medications, guidelines advise avoidance of triggers and maintaining a healthy lifestyle to prevent migraine recurrence (Mayans & Walling, 2018).  

There are two therapeutic treatment approaches when addressing an active migraine: stratified and “step” (Peters,2019). The stratified approach primarily considers headache intensity for initial medication choice, whereas the stepwise approach starts with simple analgesics and moves to more potent medications after treatment failure (Mayans & Walling, 2018).  Generally, the stratified approach is recommended given it yields quicker response time, faster headache resolution, and reduced treatment cost, particularly when patients are able to classify their headache intensity and provide a thorough history of effective treatment plans (Peters, 2019). The stepwise approach should be considered during a prolonged headache episode or in cases involving inconsistent symptom patterns (Mayans & Walling, 2018). 

Given many abortive treatments (ie: simple analgesics) are easily accessible and cost effective, they are also frequently overused, causing a self perpetuating rebound headache. These medication overuse headaches are ranked among the top-20 disability conditions globally and create serious morbidity (Peters, 2019). To avoid overuse headaches, most acute medications should be limited to less than 10 days per month (or less than 15 days per month for aspirin, acetaminophen, and NSAIDS) (Smith, 2021).

 

First line therapies

In multiple randomized trials, acetaminophen and NSAIDs showed significant efficacy in controlling mild to moderate migraines, and use should be considered in all patients (Smith, 2021). Details to consider when choosing from the multitude of simple analgesics include preparation, side effects, and time of onset. For example, Ketorolac is usually given IM, avoiding a potentially ineffective oral route in nauseous patients; naproxen has a slower onset of action but longer half life which may reduce refractory migraines; and acetaminophen is associated with less gastric upset than NSAIDs (Mayans & Walling, 2018).  

Triptans are first line treatment for moderate to severe episodes, proving effective and associated with minimal side effects (Smith, 2021). However, if treatment failure occurs with one triptan, trial of a different triptan is recommended (Peters,2019). Patients can respond better to certain triptans over others due to underlying genetic factors(Mayans & Walling, 2018). Triptans are available in a plethora of preparations and have few side effects, but expense is often a deterrent (Mayans & Walling, 2018). Sumatriptan is perhaps the most well known and cost effective triptan, available in nasal spray, pills, or subQ injections. 

The addition of 500mg of naproxen, available in combination pills with some triptans, is likely more effective than each drug alone (Smith, 2021). Use as an initial treatment for moderate/severe episodes and as a step-up therapy is appropriate.

 

Second line/Adjunct therapies

The following therapies should be considered after above medications fail or are not tolerated. Either adding or replacing medications can be advised and will be specific to the individual case. 

Dihydroergotamine, especially the intranasal preparation, shows great efficacy in managing moderate to severe episodes, but usually causes more side effects than the first line therapies (Mayans & Walling, 2018).  Nausea is the most common side effect, and providing an antiemetic in conjunction should be considered. This has the added benefit of reducing nausea associated with the migraine. Studies have proven metoclopramide IV and IM/IV prochlorperazine can be used as monotherapy for acute migraine headaches as their mechanism of action reduces migraine pain as well as controls nausea/vomiting (Smith, 2021). However, this preparation must be given in office and cannot be prescribed for at home use. Oral ondansetron is a low cost option that is commonly used, although this may only address the migraine-associated nausea and not the primary migraine (Smith, 2021). Diphenhydramine can help prevent akathisia and dystonic reaction when given IV antiemetics, but is not recommended by the American Family Physicians for the specific treatment of migraines (Mayans & Walling, 2018 ; Smith, 2021).  Dexamethasone (10 to 24 mg) IV or IM can be given after a standard abortive treatment has been given to decrease recurrence of headache (Smith, 2021).

 

Emerging Therapies

As migraine etiology is better understood, new therapies are emerging. The “biologic” class has found some success in treating episodes, using the new understanding of the migraine pathway. Hopefully, these emerging medications will help overcome the current barriers to care, like contraindications, adverse effects, and tolerability issues (Peters, 2019). 

 

Want to know more…

Update: Pharmacologic Treatment for Episodic Migraine Prevention in Adults

Emerging Treatment Options for Migraine

 

References

Mayans, L., & Walling, A. (2018). Acute Migraine Headache: Treatment Strategies. American family physician, 97(4), 243–251.

Peters G. L. (2019). Migraine overview and summary of current and emerging treatment options. The American journal of managed care, 25(2 Suppl), S23–S34.

Smith, J. h. (2021, March 29). Acute treatment of migraine in adults. UpToDate. https://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults?search=migraine&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H68879808.