Migraine Headache Management

Aka: Migraine Headache Management, Migraine Management, Acute Migraine Headache, Stratified Care of the Acute Migraine

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II. Evaluation: Severity Directs Migraine Headache Management

  1. See Migraine Abortive Medication
  2. See Migraine Prophylaxis
  3. See Migraine Management Clinic Schedule
  4. See Migraine Headache Care in the Emergency Department
  5. Migraine Disability Assessment Scale (MIDAS)
    1. https://www.mdcalc.com/calc/10521/migraine-disability-assessment-midas
  6. Stratified Approach
    1. MIDAS Grade 1-2 (No or Mild Disability)
      1. Treat with simple Analgesics
    2. MIDAS Grade 3-4 (Moderate to Severe Disability)
      1. Treat with targeted Migraine medications

III. Management: General

  1. General Measures
    1. Practice Headache Self-Help Measures (e.g. Quiet dark room)
    2. Avoid Migraine Headache Triggers (e.g. Tyramine-Vasoactive Amines)
    3. Eliminate Rebound Migraine Factors (esp. Analgesics >10 days/month)
  2. Review Migraine Abortive Medications with best efficacy and safety for the given patient
    1. Avoid Opioid and Barbiturate agents (risk of Rebound Headache, and Substance Misuse)
  3. Migraine Headache Prophylaxis is critical to the effective management of frequent Migraines
    1. See Migraine Headache Prophylaxis
    2. Frequent Migraine Headaches (4/month, 8 days/month)
    3. Prolonged Headaches >2 days with Disability
    4. Debilitating Headache despite acute Migraine abortive agents
    5. Intolerance or contraindications to acute Migraine abortive agents
    6. Analgesic Overuse Headaches or overuse of acute Migraine abortive agents
    7. Complicated Migraine Headache subtypes with prominent neurologic findings
  4. Headache protocols and precautions exist for specific patient cohorts
    1. See Migraine Headache Management in Children
    2. See Headache in Pregnancy
    3. See Migraine Medications in Pregnancy
    4. See Migraine Medications in Breast Feeding
    5. See Menstrual Migraine
    6. See Headache in HIV
  5. Exercise caution in elderly patients with Migraine Headache
    1. Consider Organic Headache (Secondary Headache)
    2. Triptans (and DHE) carry Vasocontrictor Contraindications below
    3. NSAIDS have numerous adverse effects in the elderly (e.g. GI Bleed, Acute Kidney Injury, Cardiovascular Risks)
    4. Gepants (e.g. Ubrogepant, Rimegepant, Zavegepant) may be associated with CYP450 related Drug Interactions
    5. Ditans (e.g. Lasmiditan) increase Somnolence and Fall Risk

IV. Management: Aura or mild to moderate early Acute Migraine (<2 hours, MIDAS 1-2)

  1. See Migraine Abortive Medication
  2. Advance Analgesics hourly (moving to moderate agents if not improving)
  3. NSAIDS (may be used in combination with Metoclopramide for greater effect)
    1. Ibuprofen
    2. Naproxen (Naprosyn, Anaprox DS)
    3. Diclofenac
    4. Indomethacin
  4. Combination agents (do not use Aspirin in children, increased GI irritation with Aspirin)
    1. Excedrin Migraine (Aspirin, Acetaminophen, Caffeine)
    2. Aspirin 1000 mg with Metoclopramide (see below)
      1. Tfelt-Hansen (1995) Lancet 346:923-6 [PubMed]
  5. Alternatives for NSAID intolerant patients
    1. Acetaminophen 1000 mg
    2. Celecoxib (Celebrex, Elyxyb)

V. Management: Moderate Acute Migraine Headache (<2 to 4 hours, MIDAS 3) or refractory to above

  1. See Migraine Abortive Medication
  2. Consider administering at 1 hour for failed improvement with initial meds listed above
    1. Triptans are most effective when used at Migraine Headache onset
  3. Migraine Abortive Medications (in combination with Anti-emetic, see below)
    1. First-Line
      1. Triptan agents (first-line, see below)
      2. Consider coadministration with NSAIDs
        1. Indomethacin is available as a suppository
    2. Other agents
      1. Intranasal Dihydroergotamine or DHE (Triptans are preferred, see below)
      2. Isometheptene (e.g. Midrin which also contains Acetaminophen and dichloralphenazone) may be effective
        1. However, Midrin is a controlled substance (schedule IV) due to the Sedative dichloralphenazone
        2. Generally avoided and largely replaced by Serotonin Agonists (esp. Triptans)
      3. Avoid Opioids
      4. Avoid Butalbital (e.g. Fiorinal)
        1. Barbiturate with poor efficacy
        2. Potentially addictive with risk of withdrawal
  4. Antiemetic
    1. Precautions
      1. All dopamine Antagonists risk Extrapyramidal Side Effects (warn patients to stop agent if occurs)
    2. First-line
      1. Metoclopramide (Reglan, enhances abortive medication absorption)
      2. Prochlorperazine (Compazine)
    3. Other Anti-emetics (some available as suppositories)
      1. Dimenhydrinate
      2. Hydroxyzine (Atarax)
      3. 5-HT3 Receptor Antagonist (e.g. Ondansetron)
        1. Although available as ODT, and effective in Nausea, less effective in Migraine Headache
      4. Phenergan
        1. Also a dopamine Antagonist (but may be less effective in Migraine Headache)

VI. Management: Severe Acute Migraine Headache (2-6 hours, MIDAS 4) or refractory to above

  1. See Emergency Department Migraine Headache Care
  2. See Migraine Abortive Medications
  3. Antiemetic as above
  4. Serotonin Agonist
    1. Triptans (first-line, preferred)
      1. Sumatriptan (Imitrex) - subcutaneous form is more effective than oral, intranasal
      2. Rizatriptan (Maxalt MLT) - orally disintegrating tablets
      3. Zolmitriptan (Zomig) - orally disintegrating tablets
      4. Almotriptan (Axert)
      5. Eletriptan (Relpax)
    2. Triptans (longer acting agents for recurrent Migraines)
      1. Naratriptan (Amerge, generic)
      2. Frovatriptan (Frova)
    3. Dihydroergotamine or DHE (e.g. Migranal Nasal Spray, second-line)
      1. Triptans are preferred over Dihydroergotamine
      2. Do not use within 24 hours of a Triptan
      3. Nausea is common, and reduce dose if Leg Cramps or Paresthesias may occur
    4. Triptans may have inadequate response in up to one third of Migraine Headache patients
      1. Consider switching to another Triptan
      2. Consider combining with NSAIDs
      3. Consider Rebound Headache or other Headache Causes
      4. Consider third-line agents (see below)
  5. Third-line Agents (very expensive, and overall lower efficacy than Triptans)
    1. Gepant (CGRP receptor blocker)
      1. Ubrogepant (Ubrelvy)
      2. Rimegepant (Nurtec)
      3. Zavegepant (Zavzpret)
    2. Ditan (Selective Serotonin 5-Hydroxytryptamine receptor 1F agonst or 5-HT1F Agonist)
      1. Schedule V due to euphoria and Hallucinations
      2. Lasmiditan (Reyvow)

VII. Management: Severe Acute Refractory Migraine Headache (6 to 72 hours, MIDAS 4)

  1. See Emergency Department Migraine Headache Care

VIII. Prevention

  1. See Migraine Prophylaxis
  2. See Migraine Headache Triggers (e.g. Tyramine-Vasoactive Amines)
  3. See Rebound Migraine Factors (esp. Analgesics >10 days/month)

IX. Contraindications: Vasoconstrictors (e.g. Triptans, DHE)

  1. Contraindications to Vasoconstrictors (e.g. Triptan, DHE)
    1. Coronary Artery Disease
    2. Cerebrovascular Accident history
    3. Hemiplegic Migraines
    4. Basilar Migraines
    5. Pregnancy
  2. Alternative Non-Vasoconstrictive Agents
    1. Excedrin Migraine (Acetaminophen, Aspirin, Caffeine)
    2. NSAIDS
    3. Dopamine Antagonists (e.g. Metoclopramide or Prochlorperazine)
    4. Gepant (e.g. Ubrogepant, Rimegepant, Zavegepant)
    5. Ditan (e.g. Lasmiditan)

X. References

  1. Jackson (1998) CMEA Internal Medicine Lecture,San Diego
  2. Mayans (2018) Am Fam Physician 97(4): 243-51 [PubMed]
  3. Moore (1997) Am Fam Physician 56(8):2039-48 [PubMed]
  4. Noble (1997) Am Fam Physician 56(9):2279-86 [PubMed]
  5. Polizzotto (2002) J Fam Pract 51(2):161-7 [PubMed]
  6. Silberstein (2004) Lancet 363:381-91 [PubMed]
  7. Wiley (2025) Am Fam Physician 111(4): 317-27 [PubMed]

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