Effective Migraine Management: Migraine Treatment & Strategy

Navigating Treatment Options and Lifestyle Strategies
Dr. Maisam Raza

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.

Effective Migraine Management Migraine Treatment

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
Acute Treatment


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
Navigating Treatment Options and Lifestyle Strategies

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
Nutritional Intervention

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
Migraine Treatment

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