Migraine is a common disease and about 15-20% of population suffers from it. Every physician needs to know the principles of migraine management. The current article describes the diagnostic criteria and treatment of migraine.

1. RIGHT THERAPEUTIC APPROACH TO MANAGE
MIGRAINE
DR SUDHIR KUMAR MD DM (Neurology)
Consultant Neurologist,
Apollo Hospitals, Hyderabad

2. Case 1
 History: 20 y/o female, 2 year history of headache, 4 - 6 hr duration,
frequency of 3-4/month
 Symptoms: pain (right forehead, eye extending back to occipital region,
throbbing); nausea (no vomiting); aura (some spots in vision & flashing
lights 10 min before headache); sensitivity to light and sound
 Triggers: Headaches worse with weather changes, delay in meals, sleep
deprivation
 Medications: taking oral contraceptive; tried a triptan & had some chest
“hurting”, no relief; lethargy with amitriptyline therapy
 Examination : General and neurological were normal; systolic murmur at
apex

3. Case 1
 What is best therapy at this time?
 She found one triptan failed and not tolerated..what should she do?
 What about the cardiac murmur?
 Should she try other abortive medications, if so what?
 Should she be on oral contraceptive therapy?
 Should she be on any other therapy at this time and if so what?

4. 5 steps
Migraine treatment involves
Acute (abortive) and
Preventive (prophylactic) therapy
Patients with frequent attacks usually require both.
Measures directed toward reducing migraine triggers are also generally advisable.
Amercian Headache Society
Am Fam Physician. 2011 Feb 1;83(3):271-280

5. Approach to Migraine patient
 Make a specific diagnosis
 Assess migraine severity and its impact
 Determine the patient’s preferences and needs
 Develop a therapeutic partnership
 Agree on treatment plan
Amercian Headache Society
Am Fam Physician. 2011 Feb 1;83(3):271-280

7. When to treat migraine ?
 Early treatment will
 Improve response to therapy
 Will lead to less medication use and
 Less disability
 When given during an aura, triptans do not show consistent efficacy in
aborting or preventing the migraine.
 Educate the patient to not take their triptan during the aura phase but
rather early in the pain phase of the attack
Amercian Headache Society
Am Fam Physician. 2011 Feb 1;83(3):271-280

8. Points to note
 Choice of initial acute therapy depends on
 the severity and intensity of the migraine
 the presence of comorbid conditions
 patient preferences, and
 past therapeutic response profile.
 Prescribe initial acute treatment to abort or reverse the progression of headache.
 Consider the use of one or more medications to treat recurrent headaches.
 Provide back-up medication options when initial acute therapy fails
Amercian Headache Society
Am Fam Physician. 2011 Feb 1;83(3):271-280

9. Assessing efficacy of treatment
 Explain to the patient that pain relief is different than pain-free. Ideally,
patients seek a pain-free response, but may only achieve a pain-relief status.
 Pain relief or “headache response” is commonly defined as pain intensity
originating at a 3 or 4 pain intensity (4 being severe, 0 being no pain) and
going to no pain or mild pain by 2 hours.
 Other important features is to have the patient track how well their
medication worked over a 24-hour period.
 Do they need rescue or a second dose of medication?
 Additionally, patients should monitor their ability to resume normal
activities including work, child care, and social or leisure events
Amercian Headache Society
Am Fam Physician. 2011 Feb 1;83(3):271-280

10. End Points
Pain relief (headache response)
 Onset of relief (15 minutes; 30
minutes)
 Duration of pain relief (24 hours)
Do they need rescue or a second dose of
study medication?
Patients should monitor their ability to
resume normal activities including work,
child care, and social or leisure events.
Gradual improvements in headache status
can be difficult to assess if the patient is
not aware of how to monitor
improvements or deterioration in migraine
patterns.
Explaining what to look for and how to
track attacks is an important part in
determining treatment success or failure.
Amercian Headache Society
Am Fam Physician. 2011 Feb 1;83(3):271-280

11. Patient may delay taking treatment …
 Do not know to take medicine early
 May not recognize it as migraine
 Throbbing, Nausea, Photophobia
 Aggravated by activity
 Recognize migraine aura
Amercian Headache Society
Am Fam Physician. 2011 Feb 1;83(3):271-280

12. WHEN TO ORDER BRAIN SCAN?
• Onset of migraine after the age of 50,
• Change in character or severity of headaches,
• Headache with fever or seizures,
• Most severe headache of lifetime,
• Headache lasting > 72 hours,
• Focal neurological symptoms/signs,
• Headache not responding to usual anti-migraine treatment.

13. Abortive Medication Stratification by Headache
Severity
Moderate Severe
Extremely
Severe
NSAIDs ( Also used in
mild migraine)
Naratriptan DHE (IV)
Isometheptene Rizatriptan Opioids
Ergotamine Sumatriptan (SC,NS)
Dopamine
antagonists
Naratriptan Zolmitriptan
Rizatriptan Almotriptan
Sumatriptan Frovatriptan
Zolmitriptan Eletriptan
Almotriptan DHE (NS/IM)
Dopamine
antagonists Ergotamine
Dopamine antagonists
Simple analgesics alone or
combinations ( e.g.
sumatriptan + Naproxen )
for moderately severe
headaches and sometimes
even for severe headaches.1
Acute treatment is most
effective when given within
15 minutes of pain onset
and when pain is mild
Cochrane Database Syst Rev. 2010 Nov 10.
CD008040
Neurology. 60(7):S21-3.

14. Sumatriptan + Naproxen
• Sumatriptan
• Selective
vasoconstriction of
blood vessels
Vascular
• Sumatriptan
•Reduction of trigeminal
nerve activation
•Inhibition of vasoactive
neuropeptide release
Neurogenic
• Sumatriptan
•Inhibition of
neurotransmitter release
in brainstem and upper
cervical spinal column
Central
• Naproxen
• Inhibition of PG which
leads to vasoconstriction of
blood vessels
Vascular
• Naproxen
• Reduction of trigeminal
nerve activation
Neurogenic
Synergistic
Effect

15.  Combination treatment was effective in the acute treatment of migraine headaches.
 The effect was greater than for the same dose of either sumatriptan or naproxen alone.
 More participants achieved good relief when medication was taken early in the attack, when
pain was still mild.
 Adverse events were more common with the
combination and sumatriptan alone than with
placebo or naproxen alone.
Law et al 2016

16. AAN/AHS
 Sumatriptan & Naproxen are given Level A
and Group 1
 Level A – Strong Evidence
 Group 1 - Proven pronounced statistical
and clinical benefit (at least 2 double-blind,
placebo-controlled studies + clinical
impression of effect)

17. Law et al 2016
 Combination treatment was effective in
the acute treatment of migraine
headaches.
 The effect was greater than for the same
dose of either sumatriptan or naproxen
alone.
 More participants achieved good relief
when medication was taken early in the
attack, when pain was still mild.
 Adverse events were more common with
the combination and sumatriptan alone
than with placebo or naproxen alone.

18. Hospital admission for migraine
Treatment of severe nausea, vomiting, and subsequent
dehydration
Treatment of severe, refractory migraine pain (ie, status
migrainosus)
Detoxification from overuse of combination analgesics, ergots,
or opioids
Amercian Headache Society
Am Fam Physician. 2011 Feb 1;83(3):271-280

19. TRIGGER FACTORS FOR MIGRAINE ATTACKS
• Fasting or delay in eating,
• Inadequate sleep duration,
• Stress,
• Head bath,
• Periods,
• Travel

20. Prophylactic Therapy : Indications
Frequency of migraine attacks is greater than 2 per month
Duration of individual attacks is longer than 24 hours
The headaches cause major disruptions in the patient’s lifestyle, with
significant disability that lasts 3 or more days
Abortive therapy fails or is overused
Symptomatic medications are contraindicated or ineffective
Use of abortive medications more than twice a week
Migraine variants such as hemiplegic migraine or rare headache attacks
 producing profound disruption or risk of permanent neurologic injury
Neurology. 2003. 60(7):S38-44.

21. Preventive Drugs for Migraine
1st Line High efficacy
Beta blockers
Tricyclic antidepressants
Divalproex
Topiramate
Low efficacy
Verapamil
2nd Line High efficacy
Methysergide
Flunarizine
MAOIs
Unproven
efficacy
Cyproheptadine
Gabapentin
Amercian Headache Society
Am Fam Physician. 2011 Feb 1;83(3):271-280

22.  Divalproex sodium, sodium valproate, topiramate, metoprolol,
propranolol, and timolol are effective for migraine prevention
 Should be offered to patients with migraine to reduce migraine attack
frequency and severity (Level A).
 Frovatriptan is effective for prevention of menstrual migraine (Level A).
 Lamotrigine is ineffective for migraine prevention (Level A).
American Academy of Neurology and the
American Headache Society
Neurology: 2012;78:1337–1345

23. Preventive Medication for Comorbid Conditions
 Propranolol, timolol, methysergide, valproic acid, and topiramate have been
approved by the FDA for migraine prophylaxis.
 Long-term topiramate use in pediatric patients can cause a mild risk metabolic
acidosis and hypokalemia
 In migraineurs with allodynia, prophylactic therapy with divalproex and
amitriptyline were equally effective in relieving allodynia
 Naproxen sodium should be reserved for short-term use, such as for menstrual
migraines
 Quetiapine is effective for migraine prophylaxis in patients with migraine
refractory to treatment with standard therapies (eg, atenolol, nortriptyline,
flunarizine)
Eur J Paediatr Neurol. 2010 Sep. 14(5):445-8.
Clin J Pain. 2013 Jan 16
Neurology. 2012 Apr 24. 78(17):1346-53

24. Menstrual migraine
Pure menstrual migraine
A Attacks, in a menstruating woman, fulfilling criteria for migraine without
aura
B Attacks occur exclusively on day 1 ±2 (i.e. days —2 to +3) of menstruation in
at least two out of three menstrual cycles and at no other times of the cycle
Menstrually-related migraine
A Attacks, in a menstruating woman, fulfilling criteria for migraine without
aura
B Attacks occur on day 1 ±2 (i.e. days —2 to +3) of menstruation in at least
two out of three menstrual cycles and additionally at other times of the cycle
Ther Adv Neurol Disord. 2009 Sep; 2(5): 327–336.

25. Treatment of Menstrual Migraine
Abortive therapy for menstrual migraine is the same as for nonmenstrual
migraine.
Patients with frequent and severe attacks may benefit from short-term,
perimenstrual use of preventive agents
If these patients are experiencing breakthrough menstrual migraine
headache, they may benefit from perimenstrual elevation of the dose
of the preventive medication.
Patients who do not respond to standard preventive measures may benefit
from hormonal therapy.
Perimenstrual estrogen supplementation with estradiol (0.5 mg orally
twice a day, or a 1-mg transdermal patch) may be beneficial
Neurology. 2010 Oct 26. 75(17):1527-32.

26. Status Migranosus (Attacks lasting>72 hours)
 Consider sumatriptan sc
 Start an IV and hydrate
 Start repetitive IV treatment
 Antiemetics plus DHE
 Neuroleptics
 Ketorolac 30-60 mg IM
 Opioids
 Corticosteroids
 Magnesium? Valproate?
Amercian Headache Society
Am Fam Physician. 2011 Feb 1;83(3):271-280

27. • FDA approved for migraine prevention
– Propranolol: 60-240 mg PO once daily for LA or divided BID or TID for IR
• Limited evidence for migraine prevention
– Metoprolol: 100-200 mg daily or divided BID for IR formulation
Beta Blockers
The prevention of migraine: a critical review with special emphasis on beta-adrenoceptor blockers. Br J Clin Pharmacol 2001 Sep;52(3):237-43
Advantages
 Thoroughly studied and widely
used
 Propranolol and Timolol are
FDA approved
 Good choice for patients with
HTN, tremor and anxiety
Disadvantages
 Side effects = fatigue, dizziness, depression,
exercise intolerance, may worsen aura
 Precaution in patients with severe asthma,
depression, bradycardia, Raynaud's, overt CHF

28. Special patient populations
Strategy
Children and Adolescents Use NSAIDs, triptans, behavioral
therapy (sleep, biofeedback,
stress management)
Elderly Use acetaminophen, COX-2
inhibitors, opioids, atypical
neuroleptics
Pregnancy Use acetaminophen, opioids,
corticosteroids, neuroleptics
Adverse effects Switch triptans, use a different
class, lower dose
Wolff’s Headache and Other Head Pain. 2001.

29. Key to successful Migraine Management
 Establish a partnership with the patient
 Promote patent education
 Establish a treatment plan
 Nature and mechanism of the disorder
 Identification and avoidance of triggers
 Behavioral management strategies
 Regular sleep, exercise, meals
 Stress management, biofeedback
 Cognitive behavioral therapy
 Develop pharmacologic management plan
 Acute treatment
 Preventive strategies

30. Email: drsudhirkumar@yahoo.com