See also separate related articles Migraine and Migraine Prophylaxis in Adults.
There are significant differences in the treatment of migraine in children - see separate article Migraine in Children.
Migraine cannot be cured and it is important, through careful history and diagnosis, to reach a shared aim with the patient. This should broadly be the control of symptoms to minimise the impact of the illness on the patient's life and lifestyle.
If there is doubt about the diagnosis then the following management plans should be abandoned and alternative management considered. This may include further investigation and referral. This is considered in the Migraine article above.
The detailed management will be individual to each patient, with many variables affecting the advice and treatments offered (eg severity of migraine, patient preferences, age and sex of the patient). The important elements of good migraine management are:
- Correct diagnosis with particular attention to the history.
- Explanation of diagnosis and treatments.
- Reassurance, which alone may be enough but which at least supplements other measures.
- Predisposing factor identification and management.
- Precipitating or trigger factor identification, management and avoidance.
- Other interventions (drug or nondrug).
- Follow-up of patients to adapt advice and allow further management. Further treatments can be adjusted in the traditional 'stepped management' approach (see below).
Algorithms such as that of the Migraine in Primary Care Advisors (MIPCA) and Prodigy have been published to guide management. Some favour a stratified approach where treatment is started at a level likely to be successful given the severity of the migraine. The stepped management approach described by the British Association for the Study of Headache (BASH) is supported by references and claims to allow for more rational prescribing. The disadvantage of sticking rigidly to this approach is that patients lose faith in the process, or even the doctor, as the first steps may be inadequate for more severe migraine. A stratified approach aims to select treatment appropriate for the severity of migraine. There is some evidence that a stratified approach is more effective. The current lack of evidence from comparative studies limits development of guidelines.
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Address any predisposing or trigger factors
These are factors which co-exist with migraine and may be treated to improve migraine. All patients should be given the opportunity of identifying such factors so that behaviour modification can be offered either alone or along with drug treatments.
Keeping a dual 'attack and trigger diary' when attacks are frequent may identify opportunities for behaviour modification. The diary can determine whether triggers and attacks coincide. If avoidance is possible, this may help (many triggers are unavoidable):
- Stress or even relaxation after periods of stress. Stress can include bright lights, loud noise, long-distance travel and extremes of weather.
- Anxiety or depression.
- Trauma to the head or neck.
- Dietary factors include cheese, chocolate, alcohol and citrus fruits. These are only occasionally important in management and too much effort in identifying them may be counterproductive. There is no case for 'blanket' avoidance of foods.
- Dietary sensitivities are estimated to affect no more than 20% of migraine sufferers (suspect if onset occurs within six hours of ingestion). Blanket dietary exclusions (for example, chocolate and cheese) are not recommended.
- Missed meals or fluids (dehydration).
- Sleep deprivation or excessive sleep.
- Oral contraceptives and vasodilators may precipitate or exacerbate the condition.
Treatments may range from psychological therapies to physiotherapy as appropriate. There has been a call for more research into better identification and management of comorbid psychopathology among headache patients.
Drug treatment for acute migraine
The selection of treatment should take into account patient preference, cost, safety and likely efficacy. Drug therapy should be combined with rest and sleep where possible, as this improves speed of recovery.
- Step one: simple analgesic with or without anti-emetic.
This is appropriate for mild-to-moderate migraine in a stratified approach. Often patients will already have tried and failed with some of these treatments. In these and in patients with moderate-to-severe migraine, move to step three.
- Use early in the attack to avoid gastric stasis.
- Use soluble aspirin 600-900 mg (not in children) or ibuprofen 400-600 mg.
- Avoid paracetamol (less efficacy), codeine, or dihydrocodeine (less efficacy, more nausea, more risk of medication overuse headache and addiction). Warn not to use over-the-counter products which contain codeine.
- Use prochlorperazine 3 mg buccal tablet if there is nausea and vomiting (anti-emetics are not recommended for children or adolescents).
- Consider switching to prokinetic anti-emetic in adults (improves absorption, eg domperidone or metoclopramide 10 mg).
- Consider other non-steroidal anti-inflammatory drugs (NSAIDs) ± anti-emetics (naproxen 500 mg, diclofenac 50-100 mg, tolfenamic acid 200 mg). Don't use delayed-release NSAIDs.
- Consider combination preparations (MigraMax® and Paramax®).
- Step two: rectal analgesia and rectal anti-emetic.
- Use diclofenac suppositories 100 mg with domperidone suppositories 30 mg if needed for vomiting.
- Avoid if contra-indicated or unacceptable to the patient.
- Step three: specific anti-migraine drugs - triptans or ergotamine.
In a stratified approach to management, patients identified as having moderate-to-severe migraine should move straight to step three.
TriptansTriptans work by selectively stimulating 5-hydroxytryptamine receptors in the brain and have largely replaced ergotamine which has poor bioavailability (best rectally), has more side-effects and may be misused. Ergotamine should not be taken with triptans, but is probably safe 12 hours after all but frovatriptan.
Contra-indications to triptans
- People with uncontrolled hypertension.
- People with coronary heart disease or cerebrovascular disease*.
- People with risk factors for coronary heart disease or cerebrovascular disease*.
- People with coronary vasospasm (Prinzmetal's angina)*.
- Children aged under 12 see separate Migraine in Children article.
Guidance on use of triptans Triptans should be taken during the headache phase (ineffective if taken too early before the headache has started). They have differing comparative efficacy, cost and tolerability, but there is no difference in the safety. Those triptans with greater efficacy usually cause more side-effects. Unfortunately 20-50% of patients have a return of headache within 48 hours.
- Start with standard doses of oral triptan (eg sumatriptan 50 mg, zolmitriptan 2.5 mg, rizatriptan 10 mg, almotriptan 12.5 mg, eletriptan 40 mg).
- Sumatriptan 6 mg subcutaneously is the treatment of choice if a rapid response is paramount.
- If the first choice fails to relieve the acute migraine pain adequately, consider increasing the dose of the same triptan, using a different formulation for more rapid response, or changing to a different triptan.
If first choice triptan relieves acute migraine pain but gives unacceptable side-effects:
- Use a lower dose of triptan. For example, rizatriptan 5 mg or eletriptan 20 mg (an off label recommendation).
- Use a triptan with fewer adverse effects, eg naratriptan 2.5 mg.
If immediate relapse is a problem with triptans (very common with 20-50% relapse over 48 hours reported):
- A second dose can be effective but beware repeated rebound attacks and medication overuse headache.
- Some triptans have a longer half-life, although this does not seem to mean a lower relapse rate. Relapse rates are similar for all triptans.
- Use diclofenac or tolfenamic acid pre-emptively if relapse anticipated.
- Ergotamine suppository 1-2 mg could be used because of its prolonged duration of action but should not be used within 12 hours of a triptan. Use is limited by its toxicity and misuse potential.
If more than two triptans are ineffective or migraine is very frequent:
- Review the diagnosis.
- Review concordance and determine whether the drugs are being used correctly.
- If the diagnosis is correct and the drugs are being used correctly but are not effective, try combining triptans with standard analgesia with or without anti-emetics and, if migraines are very frequent, consider using prophylactic drug treatment.
If there is nausea or there are problems taking tablets:
- Sumatriptan 20 mg nasal spray.
- Or zolmitriptan 5 mg nasal spray.
- Or rizatriptan 10 mg dissolvable wafer.
- Or dispersible zolmitriptan 2.5 mg.
If there is early vomiting:
- Sumatriptan 25 mg suppository.
- Or sumatriptan 6 mg by subcutaneous injection.
Other important scenarios
Migraine and patent foramen ovale
The triggering of migraine with aura by scuba diving should alert to the possibility of patent foramen ovale. This comorbidity reported in case-control studies and retrospective analyses may be more common than is currently appreciated. A study showed that nearly half of patients with migraine with aura have a right-to-left shunt due to patent foramen ovale. Closure of patent foramen ovale is not recommended as a prevention of migraine. Retrospective studies indicate a reduction in migraine frequency after closure intended to reduce stroke but methodological limitations apply to these studies. An RCT (the Migraine Intervention with STARFlex® Technology (MIST) trial) failed to show that closure improved migraine but identified the need for further, ongoing research.
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This is migraine occurring regularly two days before or after the onset of menstruation and at no other time. It is quite rare, occurring in fewer than 14% of women with migraine but correct diagnosis is essential for correct management. Treatment in this case can (if the women has an intact uterus and is menstruating regularly) be seven-day oestrogen patches started three days before onset of menstruation.
Migraine diaries over three months can differentiate it from the more common menstrual-associated migraine (migraine around the time of menstruation but not fulfilling criteria for menstrual migraine). Acute treatment is the same as for migraine associated with other triggers, as is prophylaxis.
Migraine and the combined oral contraceptive pill (COCP)
Both are independent risk factors for ischaemic stroke, but the risk in the absence of other risk factors is very low. COCPs are contra-indicated in:
- All women with migraine with aura, although there is not agreement amongst experts.
- Migraine without aura with more than one additional risk factor for stroke including age over 35.
- Increasingly frequent attacks of migraine without aura.
- Treatment with ergot derivatives.
- If acute migraine with aura develops whilst taking the COCP, the pill should be stopped immediately and advice on alternative or emergency contraception given.
Migraine in pregnancy and lactation
Migraine often improves in pregnancy but returns to the normal pattern after birth. The emphasis in managing migraine in pregnancy is on avoiding drugs. Therefore, identifying and avoiding triggers, and relaxation therapy, might be explored. For acute attacks, paracetamol is safe throughout pregnancy and for breast-feeding. Aspirin and ibuprofen should be avoided after 30 weeks of pregnancy (avoids the risk of premature closure of the ductus arteriosus). Aspirin should be avoided in early pregnancy and breast-feeding (risk of Reye's syndrome). For nausea, prochlorperazine is unlikely to cause harm in pregnancy or when lactating. Metoclopramide and domperidone are likely to be safe in the second and third trimesters. Triptans should be avoided during pregnancy and lactation.
Migraine with hormone replacement therapy (HRT)
The risk of stroke according to the evidence is not increased, but HRT can exacerbate migraine. Changes in type and dose of HRT may help - see Prodigy.
This is rare and also known as status migrainosus when migraine lasts longer than three days. Naproxen or diclofenac are recommended.
Slowly developing migraine
A slow build-up may mean uncertainty as to whether migraine will start or not. Use simple analgesics and avoid triptans.
Medicine overuse headache
This is a common iatrogenic problem and the introduction of prophylaxis to avoid over-frequent acute intervention is recommended.
Emergency treatment at home
Treatment for intractable migraine
New treatment with occipital nerve stimulation looks promising for patients with chronic migraine.
Sleep, relaxation, stress management, yoga and meditation all may help but further evaluation is needed. Physical fitness may help to reduce susceptibility to migraine. Acupuncture trials in the past showed no benefit in migraine. However, a recent Cochrane review on acupuncture for migraine prophylaxis has shown it to be at least as effective as prophylactic drug treatment. No benefit has yet been shown for hypnotherapy, homoeopathy and reflexology.
Too few patients with migraine are offered prophylaxis. If patients are getting two or more migraines a month, they should be offered prophylaxis. See separate article Prophylaxis of Migraine.
Further reading & references
- Tfelt-Hansen PC, Koehler PJ; One hundred years of migraine research: major clinical and scientific Headache. 2011 May;51(5):752-78. doi: 10.1111/j.1526-4610.2011.01892.x.
- Silberstein SD; Recent developments in migraine. Lancet. 2008 Oct 18;372(9647):1369-71.
- Treatment guidelines for migraine, Migraine In Primary Care Advisors (2004)
- Migraine, Prodigy (October 2010)
- Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache; British Association for the Study of Headache - BASH (2010)
- Sculpher M, Millson D, Meddis D, et al; Cost-effectiveness analysis of stratified versus stepped care strategies for acute treatment of migraine: The Disability in Strategies for Care (DISC) Study.; Pharmacoeconomics. 2002;20(2):91-100.
- Schuurmans A, van Weel C; Pharmacologic treatment of migraine. Comparison of guidelines.; Can Fam Physician. 2005 Jun;51:838-43.
- Wober C, Wober-Bingol C; Triggers of migraine and tension-type headache. Handb Clin Neurol. 2010;97:161-72.
- Penzien DB, Rains JC, Lipchik GL, et al; Future directions in behavioral headache research: applications for an evolving health care environment.; Headache. 2005 May;45(5):526-34.
- Tfelt-Hansen P; Ergotamine, dihydroergotamine: current uses and problems.; Curr Med Res Opin. 2001;17 Suppl 1:s30-4.
- Wilmshurst P, Nightingale S; Relationship between migraine and cardiac and pulmonary right-to-left shunts.; Clin Sci (Lond). 2001 Feb;100(2):215-20.
- Diener HC, Weimar C, Katsarava Z; Patent foramen ovale: paradoxical connection to migraine and stroke.; Curr Opin Neurol. 2005 Jun;18(3):299-304.
- Schwerzmann M, Nedeltchev K, Lagger F, et al; Prevalence and size of directly detected patent foramen ovale in migraine with aura.; Neurology. 2005 Nov 8;65(9):1415-8. Epub 2005 Sep 7.
- Dowson A, Mullen MJ, Peatfield R, et al; Migraine Intervention With STARFlex Technology (MIST) trial: a prospective, multicenter, double-blind, sham-controlled trial to evaluate the effectiveness of patent foramen ovale closure with STARFlex septal repair implant to resolve refractory migraine headache. Circulation. 2008 Mar 18;117(11):1397-404. Epub 2008 Mar 3.
- Goadsby PJ; Migraine: diagnosis and management. Intern Med J. 2003 Sep-Oct;33(9-10):436-42.
- Kurth T; The association of migraine with ischemic stroke. Curr Neurol Neurosci Rep. 2010 Mar;10(2):133-9.
- Menopause, Prodigy (January 2008)
- Neurophysiological tests and neuroimaging procedures in non-acute headache: guidelines and recommendations, European Federation of Neurological Societies (2004)
- EFNS guideline on the drug treatment of migraine – revised report of an EFNS task force, European Federation of Neurological Societies (August 2009)
- Matharu MS, Bartsch T, Ward N, et al; Central neuromodulation in chronic migraine patients with suboccipital stimulators: a PET study.; Brain. 2004 Jan;127(Pt 1):220-30. Epub 2003 Nov 7.
- Linde K, Allais G, Brinkhaus B, et al; Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD001218.
|Original Author: Dr Richard Draper||Current Version: Dr Hayley Willacy||Peer Reviewer: Prof Cathy Jackson|
|Last Checked: 14/12/2011||Document ID: 367 Version: 24||© EMIS|
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