Migraine Management

See related articles Migraine and Prophylaxis of Migraine.

There are significant differences in the treatment of migraine in children see 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 minimize the impact of the illness on the patient's life and lifestyle.

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 non-drug)
• 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 (MICPA)¹ and Clinical Knowledge Summaries² 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)³ 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.⁴ The current lack of evidence from comparative studies limits development of guidelines.⁵

These are factors which coexist 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.³
• Dietary sensitivities are estimated to affect no more than 20% of migraine sufferers (suspect if onset within 6 hours of ingestion). Blanket dietary exclusions (for example chocolate and cheese) are not recommended.
• Missed meals
• 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 co-morbid psychopathology among headache patients.⁶

The triggering of migraine with aura by scuba diving should alert to the possibility of patent foramen ovale.⁷ This co-morbidity reported in case-control studies and retrospective analyses may be more common than is currently appreciated.⁸ A recent study showed that nearly half of patients with migraine with aura have a right-to-left shunt due to patent foramen ovale.⁹ 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.⁸

The selection of treatment should take into account cost, safety and likely efficacy.³ Drug therapy should be combined with rest and sleep where possible as this improves speed of recovery,¹⁰ although this may be impractical where the patient's priority is to return quickly to normal activities:

1. 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.¹¹
   • Avoid paracetamol (less efficacy) codeine, or dihydrocodeine (less efficacy, more nausea, more risk of medication overuse headache and addiction). Warn not to use OTC products which contain codeine.
   • Use prochlorperazine 3 mg buccal tablet if 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 mg¹⁰)
   • Consider other NSAIDs ± anti-emetics (naproxen 500 mg, diclofenac 50-100 mg, tolfenamic acid 200 mg).³ Don't use delayed release NSAIDs.
   • Consider combination preparations (Migramax and Paramax).
2. Step two: rectal analgesia and rectal anti-emetic.
   • Use Diclofenac suppositories 100 mg with domperidone suppositories 30 mg if needed for vomiting
   • Avoid if contraindicated or unacceptable to the patient.
3. 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.

Triptans work by selectively stimulating 5-hydroxytriptamine receptors in the brain and have largely replaced ergotamine which has poor bioavailability (best rectally), has more side-effects and may be misused.

Contraindications 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 under 12 see our dedicated record - Migraine in Children.

*Note: if there is uncertainty about level of risk cardiological referral is recommended.

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.³

• 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 treatment of choice if a rapid response is paramount
• If first choice fails to adequately relieve the acute migraine pain consider increasing dose of the same triptan, using a different formulation for more rapid response, or changing to a different triptan.³

Choice of subsequent triptans can be made by looking at the data comparing speed of onset, length of effect, tolerability, cost etc but unpredictability of response supports an individualized approach which allows people to try different triptans for themselves.

If first choice triptan relieves acute migraine pain but gives unacceptable side effects:

• Use lower dose of triptan. For example rizatriptan 5 mg or eletriptan 20 mg (an off label recommendation).
• Use triptan with fewer adverse effects, eg naratriptan 2.5 mg, frovatriptan 2.5 mg, almotriptan 12.5 mg. Almotriptan has the highest sustained pain free rate and lowest adverse event rate of all oral triptans. Naratriptan has similar tolerability to placebo, prolonged efficacy and low recurrence rate.¹²

If immediate relapse is a problem with triptans (very common with 20-50% relapse over 48hrs reported)³:

• Second dose can be effective but beware repeated rebound attacks and medication overuse headache
• Consider naratriptan,¹² eletriptan,¹³ or frovatriptan¹⁴ as lower relapse is reported although some studies have not demonstrated lower relapse rates despite longer half life.¹⁵
• 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.³ Use is limited by its toxicity and misuse potential.¹⁶

If more than two triptans ineffective or migraine very frequent:

• Review the diagnosis
• Review concordance and determine whether the drugs are being used correctly
• If the diagnosis is correct and 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 nausea or 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 early vomiting:

• Sumatriptan 25 mg suppository
• Or sumatriptan 6 mg by subcutaneous injection.

Menstrual migraine

This is migraine occurring regularly 2 days before or after the onset of menstruation and at no other time. It is quite rare, occurring in less than 14% of women with migraine¹⁷ but correct diagnosis is essential for correct management. Migraine diaries can differentiate it from the more common menstrual-associated migraine. Acute treatment is the same as for migraine associated with other triggers, as is prophylaxis.

Migraine and the combined hormonal contraceptive (CHC)

Both are independent risk factors for ischaemic stroke, but the risk in the absence of other risk factors is very low. CHCs are contraindicated in:

• All women with migraine with aura, although there is not agreement amongst experts³
• 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 CHC it 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 so that identifying and avoiding triggers, relaxation therapy should 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 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 Clinical Knowledge Summaries.²

Long-duration migraine

This is rare and also known as status migranosus when migraine lasts longer than 3 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 problem¹⁷ and the introduction of prophylaxis to avoid over frequent acute intervention is recommended.

Emergency treatment at home

BASH recommend diclofenac 75 mg im rather than narcotics, with or without chlorpromazine 25 mg im for its sedative and anti-emetic effect.³

Treatment for intractable migraine

New treatment with occipital nerve stimulation looks promising for patients with chronic migraine.¹⁸

Non-drug treatments

Sleep, relaxation, stress management, yoga and meditation all may help but further evaluation is needed. Physical fitness may help reduce susceptibility to migraine. Acupuncture trials have so far not proved benefit.¹⁷ The same so far can be said of hypnotherapy, homoeopathy and reflexology.³

See separate article on Prophylaxis of Migraine.