Effective Migraine Management: Migraine Treatment & Strategy

It should be noted that as a general rule 5-HT receptor agonists are used in the acute treatment of migraine whilst 5-HT receptor antagonists are used in prophylaxis. NICE (National Institute for Health and Care Excellence) produced guidelines in 2012 on the management of headache, including migraines.

Acute Treatment

• first-line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol

• for young people aged 12-17 years consider a nasal triptan in preference to an oral triptan

If the above measures are not effective or not tolerated offer a non-oral preparation of metoclopramide or prochlorperazine and consider adding a non-oral NSAID or triptan

• caution should be exercised when prescribing metoclopramide to young patients as acute dystonic reactions may develop

Prophylaxis

Prophylaxis should generally be given if ‘Migraine attacks are having a significant impact on quality of life and daily function, for example they occur frequently (more than once a week on average) or are prolonged and severe despite optimal acute treatment

NICE CKS advise one of the following:

• propranolol

• topiramate: should be avoided in women of childbearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives

• amitriptyline

if these measures fail NICE recommends a course of up to 10 sessions of acupuncture over 5-8 weeks. 

• NICE Recommendation: Advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people

• for women with predictable menstrual migraine treatment NICE recommend either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of ‘mini-prophylaxis’

• treatment options that may be considered by specialists, but fall outside the NICE guidelines:

• candesartan: recommended by the British Association for the Study of Headache guidelines

• monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor: examples include erenumab

• pizotifen is no longer recommended. Adverse effects such as weight gain & drowsiness are common

Nutritional Intervention

• Patients find that their migraine is precipitated by diet. Alcohol, fasting, and cheese are factors most frequently reported (Finocchi and Sivori, 2012)

• Caffeine and foods containing phenylalanine, nitrates and nitrites (Sun-Edelstein and Mauskop, 2009) may also be problematic

• Melatonin and vitamin D may be beneficial (Barbanti et al, 2012)

• Following supplements may be effective for migraine;
  magnesium, CoQ10, riboflavin, butterbur, feverfew, and cyanocobalamin with folate and pyridoxine

• Evening primrose, red pepper, willow, and ginger have been recommended; no studies however have proven efficacy. Avoid herbal teas that contain toxic ingredients

Care Plans and Counseling

• Encourage the patients to identify the individual triggers and avoid items containing trigger ingredients

• Obesity is a factor in some chronic daily headaches; weight loss may be indicated

• Promote regular mealtimes, regular exercise and adequate relaxation, smoking cessation. Regular sleeping patterns are needed; evaluate for insomnia or sleep apnea

• Fasting can increase the likelihood of a headache. Regular mealtimes are important

• Discuss possibility of medication overuse headache if patient is taking long term analgesia

• Evidence based treatments include patients education, cognitive behavioural therapy, biofeedback, relaxation training and stress management