II. Evaluation: Direct Headache Management per Headache severity
- Migraine Disability Assessment Scale (MIDAS)
III. Management: General Measures
- See Headache Self-Help Measures (e.g. Quiet dark room)
- Eliminate Rebound Migraine Factors
- Avoid Opioid agents
- See Migraine Headache Management in Children
- See Headache in Pregnancy
IV. Management: Aura or mild to moderate early Migraine (<2 hours)
- Advance Analgesics hourly
- NSAIDS
- Combination agents (do not use Aspirin in children, increased GI irritation with Aspirin)
- Excedrin Migraine (Aspirin, Acetaminophen, Caffeine)
- Aspirin 1000 mg with Metoclopramide (see below)
- Alternatives for NSAID intolerant patients
- Acetaminophen 1000 mg
- COX2 Inhibitors
V. Management: Moderate Migraine Headache (<2 to 4 hours) refractory to above
- Consider administering at 1 hour for failed improvement with initial meds listed above
- Abortive Medications (in combination with Anti-emetic, see below)
- First-Line
- Triptan agents (first-line, see below)
- Consider coadministration with NSAIDs (Indomethacin is available as a suppository)
- Other agents
- Intranasal Dihydroergotamine or DHE (Triptans are preferred, see below)
- Isometheptene (e.g. Midrin which also contains Acetaminophen and dichloralphenazone) may be effective
- However, Midrin is a controlled substance (schedule IV) due to the Sedative dichloralphenazone
- Generally avoided and largely replaced by Serotonin Agonists (esp. Triptans)
- Avoid Opioids
- Avoid Butalbital (e.g. Fiorinal)
- Barbiturate with poor efficacy
- Potentially addictive with risk of withdrawal
- First-Line
-
Antiemetic
- First-line (dopamine Antagonists, warn patients regarding Extrapyramidal Side Effects)
- Metoclopramide (Reglan, enhances abortive medication absorption)
- Prochlorperazine (Compazine)
- Other Anti-emetics (some available as suppositories)
- First-line (dopamine Antagonists, warn patients regarding Extrapyramidal Side Effects)
VI. Management: Severe Migraine Headache (2-6 hours) refractory to above
- See Emergency Department Migraine Headache Care
- Antiemetic as above
-
Serotonin Agonist
-
Triptans (first-line, preferred)
- Sumatriptan (Imitrex) - subcutaneous form is more effective than oral, intranasal
- Rizatriptan (Maxalt MLT) - orally disintegrating tablets
- Zolmitriptan (Zomig) - orally disintegrating tablets
- Almotriptan (Axert)
- Eletriptan (Relpax)
-
Triptans (longer acting agents for recurrent Migraines)
- Naratriptan (Amerge, generic)
- Frovatriptan (Frova)
-
Dihydroergotamine or DHE (e.g. Migranal Nasal Spray, second-line)
- Do not use within 24 hours of a Triptan
- Nausea is common, and reduce dose if Leg Cramps or Paresthesias may occur
-
Triptans (first-line, preferred)
VII. Management: Severe Refractory Migraine Headache (6 to 72 hours)
VIII. Management: Vasocontrictor Contraindications
- Patients in whom Vasoconstrictors (e.g. Triptan, DHE) are contraindicated
- Coronary Artery Disease
- Hemiplegic Migraines
- Basilar Migraines
- Alternative agents
- Excedrin Migraine (Acetaminophen, Aspirin, Caffeine)
- NSAIDS
- Dopamine Antagonists (e.g. Metoclopramide or Prochlorperazine)
IX. References
- Jackson (1998) CMEA Internal Medicine Lecture,San Diego
- Mayans (2018) Am Fam Physician 97(4): 243-51 [PubMed]
- Moore (1997) Am Fam Physician 56(8):2039-48 [PubMed]
- Noble (1997) Am Fam Physician 56(9):2279-86 [PubMed]
- Polizzotto (2002) J Fam Pract 51(2):161-7 [PubMed]
- Silberstein (2004) Lancet 363:381-91 [PubMed]