Atypical signs or symptoms warranting urgent evaluation include:

• Fever
• New neurological deficit
• Thunderclap headache (sudden onset of severe headache, maximum intensity immediately or within <60 seconds)

  Thunderclap headache

  Thunderclap headache is a sudden-onset severe headache, with maximum intensity immediately or within <60 seconds. Thunderclap headache is a neurologic emergency that requires first and foremost evaluation for:

  • Subarachnoid hemorrhage

  Other secondary causes to consider include:

  • Intracerebral hemorrhage
  • Cerebral venous thrombosis
  • Unruptured vascular malformation (mostly aneurysm)
  • Arterial dissection (intra- and extra-cranial)
  • Reversible cerebral vasoconstriction syndrome (RCVS)
  • Pituitary apoplexy
  • Meningitis
  • Colloid cyst of the third ventricle
  • Spontaneous intracranial hypotension (CSF leak)
  • Acute sinusitis (particularly with barotrauma)

  Primary causes may include:

  • Primary thunderclap headache (diagnosis of exclusion)
  • Primary headache associated with sexual activity (diagnosis of exclusion)
  • Symptoms of transient ischemic attack or stroke
  • Signs and symptoms of meningitis (e.g., fever, chills, neck stiffness)
  • Neurological symptoms not consistent with typical aura symptoms (e.g., prolonged or persistent neurologic deficits, seizures)

• Headache during sexual activity

  Headache during sexual activity

  A headache may be triggered by sexual activity, increase with sexual excitement, or become explosive and abrupt just before or with orgasm.Secondary causes may include:

  • Subarachnoid hemorrhage
  • Intra- and extra-cranial arterial dissection
  • Reversible cerebral vasoconstrictive syndrome (RCVS)

  See American College of Radiology (ACR) Appropriateness Criteria for Headache for imaging guidance.

  If secondary causes are ruled out, the headache is considered primary headache associated with sexual activity.

Atypical signs or symptoms warranting imaging or additional tests include:

• A new, first, or worst headache
• Significant change in headache characteristics
• Increasing frequency of headache attacks or loss of pain free periods
• Headache not responding to treatment
• Existing conditions that predispose to secondary headaches (e.g., pregnancy, cancer, immunosuppression, anticoagulants)
• Signs and symptoms of systemic illness (e.g., weight loss, fever, jaw claudication, hypertension)
• New or unexplained abnormalities on neurologic examination, such as papilledema (see Headache with papilledema)

  Headache with papilledema

  Papilledema is optic disc edema associated with increased intracranial pressure.

  Secondary causes may include:

  • Intracranial space-occupying lesions
  • Cerebral venous sinus thrombosis
  • Intracranial hemorrhage
  • Decreased flow through arachnoid granulations from previous inflammation (e.g., meningitis, subarachnoid hemorrhage)
  • Arteriovenous malformation and dural shunt
  • Hypervitaminosis A
  • Tetracycline antibiotics (e.g. doxycycline, minocycline)

  If other causes are ruled out, idiopathic intracranial hypertension should be considered, especially in young female patients who are obese and those who have transient visual obscurations (brief gray, black, or whiteout of vision affecting one or both eyes).

  In an acute setting, the primary diagnostic test is computed tomography of the brain without contrast. In a non-acute setting, diagnostic tests may include magnetic resonance imaging and magnetic resonance venography of the brain. Lumbar puncture should be used only if no intracranial space-occupying lesions are found.

  Additional diagnostic steps include:

  • Ophthalmologic examination
  • Routine cerebrospinal fluid analysis with measurement of opening pressure

• Headache that is worse while standing and better while supine (see Orthostatic headache)

  Orthostatic headache

  An orthostatic headache is worse while standing and better while supine.

  An orthostatic headache may be caused by a cerebrospinal fluid (CSF) leak, which may be spontaneous or secondary (e.g., following lumbar puncture).

  Other symptoms associated with a CSF leak may include:

  • Neck or inter-scapular pain (sometimes orthostatic)
  • Tinnitus or other changes in hearing
  • Dizziness
  • Nausea (often orthostatic)
  • Photophobia

  In some cases, orthostatic headache is associated with:

  • Postural orthostatic tachycardia syndrome or autonomic dysregulation
  • Cervicogenic headache

  If a spontaneous CSF leak is suspected, magnetic resonance imaging of the head with gadolinium is warranted.

• Headache triggered by coughing, sneezing, Valsalva, or similar straining maneuver (see Cough headache)

  Cough Headache

  Cough headache is triggered by coughing, sneezing, Valsalva, or similar straining maneuver.

  Secondary causes may include:

  • Arnold-Chiari malformation
  • Spontaneous intracranial hypotension
  • Carotid or vertebrobasilar disease
  • Middle cranial or posterior fossa tumor
  • Colloid cyst
  • Subdural hematoma
  • Cerebral aneurysm
  • Reversible cerebral vasoconstriction syndrome (RCVS)

  Approximately 40% of patients have an underlying structural disease.

  See American College of Radiology (ACR) Appropriateness Criteria for Headache for imaging guidance.

  If other causes are ruled out, the headache is considered primary cough headache.

• Headache precipitated by exercise (see Exercise headache)

  Exercise headache

  Exercise headache is precipitated by any form of exercise in the absence of any intracranial disorder.

  Subarachnoid hemorrhage, arterial dissection, and reversible cerebral vasoconstriction syndrome must be ruled out on first occurence.

  See American College of Radiology (ACR) Appropriateness Criteria for Headache for imaging guidance.

  Primary causes may include:

  • Primary exercise headache
  • Migraine with or without aura

• Headache developing only during sleep, causing wakening (see Hypnic headache)

  Hypnic headache

  Hypnic headache is a recurring headache developing only during sleep, causing wakening.

  Secondary causes may include:

  • Obstructive sleep apnea
  • Nocturnal hypertension
  • Hypoglycemia
  • Medication-overuse headache
  • Intracranial space-occupying lesion

  Primary causes may include:

  • Hypnic headache
  • Cluster headache
  • Migraine with or without aura

• “Side-locked” headache (exclusively on one side of the head)
• New-onset headache after age 50 (consider giant cell arteritis)

  Giant cell arteritis

  Although the cause of giant cell arteritis is unknown, it typically occurs in older adults. Prompt treatment with corticosteroids is critical in order to prevent permanent tissue damage and loss of vision.

  Initial blood tests include:

  • Erythrocyte sedimentation rate
  • C-reactive protein
  • Complete blood count with differential

  The best way to confirm a diagnosis of giant cell arteritis is with a temporal artery biopsy.

  Consider rheumatology consult.

Neuroimaging is not usually warranted for a patient with a history of migraine with stable headaches who has a normal neurologic exam. However, imaging may be warranted in a patient with atypical signs and symptoms or in a patient who does not fall within the strict definition of migraine (or has some additional risk factor) and does not otherwise require urgent evaluation.

Migraine commonly presents with mid-face pain (leading the patient to suspect they are having sinus problems) and pain at the base of the skull (leading the patient to believe they are having neck problems). These are common migraine symptoms and not considered atypical.

ED Management

ED evaluation of headache

Non-contrast computed tomography (CT) of the head

An emergency non-contrast CT scan of the head is usually the initial test in evaluating headache emergencies.

Additional work-up for secondary headache will depend on the clinical situation.  If secondary causes of headache have been ruled out with appropriate investigations, and migraine is diagnosed, proceed to ED treatment of migraine.

ED treatment of migraine

First line per the AHS guidelines:

• Sumatriptan 6 mg subcutaneous (may repeat once in 1 hour for maximum dose of 12 mg in 24 hours)

  • Many patients may not have taken a triptan before the ED visit so giving a triptan may be a reasonable option.

• Metoclopramide 10 mg IV (dose may be repeated)

or

• Prochlorperazine 10 mg IV

  • Consider extrapyramidal reactions

    Caution regarding extrapyramidal reactions (antiemetics)

    All of the antiemetic agents listed have dopamine antagonist activity (and may additionally have anti-muscarinic and/or antihistamine) activity. Extrapyramidal reactions may occur, especially in the elderly or if used concomitant with agents likely to cause extrapyramidal side effects.

    Diphenhydramine or benztropine should not be administered routinely prior to single doses of neuroleptic antiemetics unless the patient has a history of an extrapyramidal reaction (dystonia or akathisia) to the chosen antiemetic. Diphenhydramine 25 mg IV should be used if an extrapyramidal reaction occurs following administration of an antiemetic. Neuroleptic antiemetics should be avoided in patients with Parkinson disease or dementia with Lewy body disease.

  • If IV access cannot be established, consider IM administration

• Dexamethasone 10-24 mg IM or IV once

  • Dexamethasone has been shown to prevent migraine recurrence

Additional options, in no particular order, if contraindications or history of treatment failure with above options include:

• IV hydration with 0.9% normal saline, 1 L over 1 hour
• Ketorolac 15 to 30 mg IV

  • May repeat ketorolac 15 to 30 mg every 6 hours or acetaminophen 1000 mg every 4 to 6 hours if needed
  • Studies on ketorolac for headache have been mostly done with 30 mg doses, but recent data suggest that lower doses exhibit a ceiling effect and may be effective

• Acetaminophen 1000 mg PO or IV
• Chlorpromazine 12.5 mg IV as a slow infusion

  • Consider extrapyramidal reactions

    Caution regarding extrapyramidal reactions (antiemetics)

    All of the antiemetic agents listed have dopamine antagonist activity (and may additionally have anti-muscarinic and/or antihistamine) activity. Extrapyramidal reactions may occur, especially in the elderly or if used concomitant with agents likely to cause extrapyramidal side effects.

    Diphenhydramine or benztropine should not be administered routinely prior to single doses of neuroleptic antiemetics unless the patient has a history of an extrapyramidal reaction (dystonia or akathisia) to the chosen antiemetic. Diphenhydramine 25 mg IV should be used if an extrapyramidal reaction occurs following administration of an antiemetic. Neuroleptic antiemetics should be avoided in patients with Parkinson disease or dementia with Lewy body disease.

• Valproic acid 1000 mg IV

  • Caution in women of childbearing potential who are not using effective contraception.

• Magnesium sulfate 1 g IV
• Extracranial nerve block(s)
• Consider dihydroergotamine (DHE)

  • Most patients at this point in the treatment algorithm will have a contraindication to DHE, either because they have received a triptan in the last 24 hours or because many DHE contraindications overlap with those of triptans. However, DHE can be particularly useful for hospitalized patients with status migrainosus (once no contraindications exist) but is also sometimes used in the emergency department or outpatient settings.

    Contraindications (DHE)

    Contraindications to dihydroergotamine (DHE) include:

    • Pregnancy
    • History or suspicion of ischemic heart disease
    • History of coronary artery disease or vasospastic (Prinzmetal) angina
    • Severe peripheral vascular disease
    • Onset of chest pain following test dose of DHE
    • Use of a triptan within past 24 hours
    • Elevated blood pressure (uncontrolled hypertension)
    • Previous adverse reaction
    • Migraine with brainstem aura
    • Use of an MAO inhibitor (e.g., phenelzine) within past 2 weeks

  • Droperidol 2.5 mg IV

    • Consider QTc prolongation

  • Haloperidol 1 mg IV

    • Consider QTc prolongation

    Caution regarding QTc prolongation (antiemetics)

    Some antiemetics have been associated with QTc prolongation. Droperidol and haloperidol carry the highest risk. Risks are dose dependent. An ECG is not required before administering these medications at recommended doses, but these medications should be avoided if a previous ECG shows a prolonged QTc > 500ms.  A pretreatment ECG or electrolyte panel should be considered in patients who have been vomiting and could have hypokalemia or hypomagnesemia that might further increase risk of QTc prolongation.

  • Promethazine 25 mg IM

    • Due to risk of severe tissue injury, including gangrene, preferred route of administration for promethazine is PO, rectal, or deep intramuscular (IM). Avoid IV. Subcutaneous is contraindicated.

  Opioids are generally inappropriate for acute migraine treatment and should be carefully considered on a case by case basis. Patients already using opioids >9 days per month for headache management may have a component of medication-overuse headache. Patients should not be discharged from the emergency department with a new opioid prescription.

Consider additional tests based on clinical presentation

Additional tests based on clinical presentation may include:

• Erythrocyte sedimentation rate and C-reactive protein – In patients aged 50 years or older with new or changed headache patterns
• CT of the head – In patients with acute presentation of headache associated with trauma or focal neurological signs
• MRI of the head and brain with and without gadolinium contrast
• Lumbar puncture (may require consultation with a neurologist – In patients with suspected intracranial infection or intracranial hyper or hypotension. The presence of focal neurological signs, coma and/or papilledema require neuroimaging prior to lumbar puncture.

Initiate common analgesics

An individualized strategy for migraine treatment is required because no single approach is preferred for all patients.

To prevent medication-overuse headache, acute treatment should be limited to ≤14 days/month for simple analgesics and ≤9 days/month for combination analgesics, triptans, ergot derivatives OR opioids.

Non-specific medications

Treatment goals for acute migraine symptoms

• Relieves attack severity within 2 hours
• Restores ability to function
• Minimizes use of back-up and rescue medications
• Optimizes self-care
• Reduces subsequent use of medical resources
• Limits or eliminates adverse effects

Reassess in 6-12 months

Treatment goals should be reassessed in 6 to 12 months.

If goals are still met, the non-specific medication regimen should be continued.

If goals are no longer met, consider reasons for failure of treatment goals and adjust therapy.

Consider failure of treatment goals and adjust therapy

Failure to reach treatment goals may be caused by:

• Medication overuse

  Medication overuse headache (MOH)

  Overuse of acute pain relievers can lead to medication-overuse headache (MOH), which:

  Occurs on ≥15 days per month as a consequence of the regular overuse of acute or symptomatic headache medication for >3 months (what constitutes “overuse” varies, depending on the type of medication).

  Medication overuse headache usually, but not invariably, resolves after the overuse is stopped.

  Diagnostic criteria for medication-overuse headache are:

  1. Headache occurring on ≥15 days/month in a patient with a pre-existing headache disorder
  2. Regular overuse for >3 months of one or more acute/symptomatic treatment drugs

     1. Ergotamine, triptans, opioids, or combination analgesics on ≥10 days/month
     2. Simple analgesics on ≥15 days/month
     3. Any combination of ergotamine, triptans, simple analgesics, NSAIDs, and/or opioids on ≥10 days/month without overuse of any single drug class alone

  3. Not better accounted for by another ICHD-3 diagnosis

  To prevent MOH, it is important to counsel a patient to limit acute headache medication use. The patient needs to adhere to the following acute medication restrictions. Note that days/month restrictions refer to consecutive or nonconsecutive days:

  • ≤14 days/month of NSAIDs, aspirin, or acetaminophen
  • ≤9 days/month of combination analgesics (e.g., aspirin/acetaminophen/caffeine, triptans, ergot derivatives OR opioids

  Different medication classes can be combined on a given day. For example, a patient may combine over-the-counter combination analgesics (e.g., aspirin/acetaminophen/caffeine) and a triptan on the same day as long as he or she adheres to the dose restrictions for each agent. However, a patient should not take triptans for 8 days and also take aspirin/acetaminophen/caffeine for 10 days, as this would equal 18 days and exceed the recommended limitation of ≤9 days/month of combination analgesics, triptans, ergot derivatives, OR opiates.

  Butalbital-containing analgesics (e.g., butalbital/acetaminophen/caffeine, butalbital/aspirin/caffeine) and opioids should be avoided for recurrent headache disorders because of their associated risks of: medication-overuse headache, dependence or addiction syndromes, chronification of migraine, and heightened sensitivity to pain.

  In the setting of medication overuse, migraine preventives may be less effective or even ineffective.

• Late use of medication
• Inadequate medication for degree of disability
• Poor match between medication and disabling symptoms (e.g., using oral agents for a patient with vomiting)
• Inappropriate route of administration (e.g., using oral agents for a headache in which maximum disability occurs quickly)
• Failure to use adjunctive medication (e.g., antiemetics)
• Barriers to adherence
• Inaccurate diagnosis

After correcting for any of these factors, a trial of an alternative non-specific medication should be considered.

Moderate-severe

Headache interferes with or prevents daily routine.

Start a migraine specific treatment

Migraine-specific treatments: Migraine-specific drugs (e.g., triptans, gepants, ditans and DHE) can be used if common analgesics do not provide adequate relief. Migraine-specific drugs are more efficacious than non-specific analgesics, particularly when migraine episodes result in pronounced disability.  Migraine specific treatments can be combined with anti-emetics and NSAIDs.

• Administration and dosage of triptans

  Administration and dosage of triptans

  Triptan	Formulations	Administration (mg)	Typical dose (mg)	May repeat after	Max dose/24 hrs (mg)
  Almotriptan	Tablet	6.25, 12.5	12.5	2 hours	25
  Eletriptan	Tablet	20, 40	40	2 hours	80
  Frovatriptan	Tablet	2.5	2.5	2 hours	7.5
  Naratriptan	Tablet	1, 2.5	2.5	4 hours	5
  Rizatriptan	Tablet, oral disintegrating tablet	5, 10	10	2 hours	30
  Sumatriptan	Tablet Nasal spray Subcutaneous	25, 50, 100 5, 20 3, 6	50-100 20 6	2 hours 2 hours 1hour	200 40 12
  Zolmitriptan	Tablet, oral disintegrating tablet, nasal spray	2.5, 5	5	2 hours	10

  Tips

  • Consider contraindications for triptan use

    Contraindications for triptan use

    Contraindications to triptans include:

    • Known or suspected ischemic coronary artery disease (e.g. angina pectoris, documented silent ischemia, myocardial infarction, vasospastic “Prinzmetal” angina)
    • History of stroke or transient ischemic attack
    • Uncontrolled hypertension
    • Peripheral vascular disease
    • Ischemic bowel disease
    • Wolff-Parkinson-White or other cardiac accessory conduction pathway-associated dysrhythmias
    • Use of ergot agents (e.g., dihydroergotamine [DHE]) or triptans in the previous 24 hours
    • Use of monoamine oxidase inhibitors in the previous 2 weeks
    • Severe hepatic impairment

      In addition, triptans are usually avoided in hemiplegic migraine or migraine with brainstem aura.

      Currently available evidence does not support limiting the use of triptans with serotonin-specific reuptake inhibitors (SSRIs) or serotonin–norepinephrine reuptake inhibitors (SNRIs), or the use of triptan monotherapy, due to concerns for serotonin syndrome.

• Administration and dosage of gepants

  Administration and dosage of gepants

  Gepant	Administration (mg)	Typical dose (mg)	May repeat after	Maximal dosage per day (mg)
  Ubrogepant	Tablet, 50, 100	50-100	2 hours	200
  Rimegepant	Tablet, 75	75	N/A	75

  Tips

  • The gepants have several drug interactions that require adjustment to drug dose/frequency or avoidance.

• Administration and dosage of ditans

  Administration and dosage of gepants

  Ditan	Administration (mg)	Typical dose (mg)	May repeat after	Maximal dosage per day (mg)
  Lasmiditan	Tablet, 50, 100, 200	50-200 mg	N/A	200

  Tips

  • Because of CNS depression, patients should not engage in activities requiring mental alertness, such as driving or operating heavy machinery, for at least 8 hours after taking.
  • Use caution with other agents that can cause CNS depression, including alcohol.

• Administration and dosage of anti-emetics

  Administration and dosage of anti-emetics

  Agent	Route	Single-dose quantity
  Prochlorperazine	Oral Rectal	5 to 10 mg every 6 to 8 hours, as needed 25 mg every 12 hours, as needed
  Promethazine	Oral or rectal	25 mg every 4 to 6 hours, as needed
  Metoclopramide	Oral	5 to 10 mg every 6 to 8 hours

  Tips

  • The risk of tardive dyskinesia increases with duration of exposure and cumulative dose.

• Current licensed neuromodulation devices for acute treatment of migraine

  Current licensed neuromodulation devices for acute treatment of migraine

  These devices are FDA cleared but efficacy has not been evaluated by the FDA.
  Device	Company website	Technology description	Estimated cost to patient	Prescription instructions	Major contraindications
  Cefaly dual	cefaly.com	TENS unit applied to forehead to stimulate supraorbital nerves	$399	Use for 60 minutes as-needed for acute attacks	Implanted metallic or electronic device in the head. Subjects with a cardiac pacemaker or defibrillator
  gammaCore	gammacore.com	Non-invasive vagal nerve stimulator	$600/month	Two 2-minute stimulations, which can be repeated after 20 minutes, and once more after 2 hours.	Active, implantable medical device (e.g., pacemaker), clinically significant hypotension or bradycardia, metallic devices at or near the neck, or concurrent use of another device at the same time
  Spring TMS mini	eneura.com	Transcranial magnetic stimulation pulse over occipital head region	$750/3 months	Two pulses at onset of migraine. May repeat after 24 hours.	Implants affected by a magnetic field
  Nerivio	theranica.com	Remote electrical neuromodulation	$99/12 treatments	Use for 45 minutes as-needed for acute attacks	Active implantable medical device, such as a pacemaker, hearing aid implant, or any implanted electronic device, severe cardiac or cerebrovascular disease, uncontrolled epilepsy.

Access resources about picking an acute migraine treatment here.

Consider reasons for treatment failure

Failure to reach treatment goals may be caused by:

• Acute medication overuse

  Medication overuse headache (MOH)

  Overuse of acute pain relievers can lead to medication-overuse headache (MOH), which:

  Occurs on ≥15 days per month as a consequence of the regular overuse of acute or symptomatic headache medication for >3 months (what constitutes “overuse” varies, depending on the type of medication).

  Medication overuse headache usually, but not invariably, resolves after the overuse is stopped.

  Diagnostic criteria for medication-overuse headache are:

  1. Headache occurring on ≥15 days/month in a patient with a pre-existing headache disorder
  2. Regular overuse for >3 months of one or more acute/symptomatic treatment drugs

     1. Ergotamine, triptans, opioids, or combination analgesics on ≥10 days/month
     2. Simple analgesics on ≥15 days/month
     3. Any combination of ergotamine, triptans, simple analgesics, NSAIDs, and/or opioids on ≥10 days/month without overuse of any single drug class alone

  3. Not better accounted for by another ICHD-3 diagnosis

  To prevent MOH, it is important to counsel a patient to limit acute headache medication use. The patient needs to adhere to the following acute medication restrictions. Note that days/month restrictions refer to consecutive or nonconsecutive days:

  • ≤14 days/month of NSAIDs, aspirin, or acetaminophen
  • ≤9 days/month of combination analgesics (e.g., aspirin/acetaminophen/caffeine, triptans, ergot derivatives OR opioids

  Different medication classes can be combined on a given day. For example, a patient may combine over-the-counter combination analgesics (e.g., aspirin/acetaminophen/caffeine) and a triptan on the same day as long as he or she adheres to the dose restrictions for each agent. However, a patient should not take triptans for 8 days and also take aspirin/acetaminophen/caffeine for 10 days, as this would equal 18 days and exceed the recommended limitation of ≤9 days/month of combination analgesics, triptans, ergot derivatives, OR opiates.

  Butalbital-containing analgesics (e.g., butalbital/acetaminophen/caffeine, butalbital/aspirin/caffeine) and opioids should be avoided for recurrent headache disorders because of their associated risks of: medication-overuse headache, dependence or addiction syndromes, chronification of migraine, and heightened sensitivity to pain.

  In the setting of medication overuse, migraine preventives may be less effective or even ineffective.

• Late use of medication
• Inadequate medication for degree of disability
• Poor match between medication and disabling symptoms (e.g., using oral agents for a patient with vomiting)
• Inappropriate route of administration (e.g., using oral agents for a headache in which maximum disability occurs quickly)
• Failure to use adjunctive medication (e.g., antiemetics)
• Barriers to adherence
• Inaccurate diagnosis

Preventive Treatment Plan

In general, the need for prevention is determined by the frequency of headache and migraine-related impairment.

Indication for migraine prevention 

Additional indications

Prevention should also be considered if 1 or more of the following is present:

• Failure of, overuse of, or contraindication to acute treatment
• Adverse effects of acute treatment
• Hemiplegic migraine, basilar migraine, migraine with prolonged aura, migrainous infarction, or other rare migraine condition that can potentially cause neurologic damage

Commonly used medications for migraine prevention

(In no particular order)

*FDA approved

Selecting a preventive agent

• Therapeutic opportunities that allow a single drug to prevent migraine episodes while also treating a coexisting condition should be considered.
• Patient preference should be respected (e.g., some preventive agents may increase weight, decrease weight, or cause sedation which may or may not be desirable).
• Consider contraception in women of childbearing age.
• Migraine prevention is often discontinued during pregnancy.

Access resources about picking a preventive migraine treatment here.

Current licensed neuromodulation devices for migraine prevention

Adjunctive therapy 

Adjunctive therapy for migraine in an adult may include:

• Acupuncture
• Biofeedback
• Cognitive behavior therapy
• Relaxation training
• Support groups

Goals of migraine prevention

• Decrease episode frequency, severity, and duration
• Improve responsiveness to treatment of acute attacks
• Improve function and decrease disability
• Decrease cost of migraine management

Realistic expectations should be discussed ahead of time to prevent frustration. Prevention is considered successful if headache frequency is decreased by ≥50% following a 3-6 month treatment trial.

Continue preventive agent

While no guidelines exist, it is good practice to discuss tapering or discontinuing a preventive agent after ~1 year of “good” migraine control.

However, a patient who previously had frequent disabling episodes and has found a successful preventive agent may choose to continue prevention for a longer period of time or sometimes indefinitely.

Consider reasons for failure of prevention and adjust therapy

The most common reasons for failure of migraine prevention include:

• Insufficient dose of preventive agent
• Insufficient duration of preventive trial (maximum clinical benefit may not be noted until 3 months of use at the target dose)
• Poor patient compliance
• Medication overuse

  Medication overuse headache (MOH)

  Overuse of acute pain relievers can lead to medication-overuse headache (MOH), which:

  Occurs on ≥15 days per month as a consequence of the regular overuse of acute or symptomatic headache medication for >3 months (what constitutes “overuse” varies, depending on the type of medication).

  Medication overuse headache usually, but not invariably, resolves after the overuse is stopped.

  Diagnostic criteria for medication-overuse headache are:

  1. Headache occurring on ≥15 days/month in a patient with a pre-existing headache disorder
  2. Regular overuse for >3 months of one or more acute/symptomatic treatment drugs

     1. Ergotamine, triptans, opioids, or combination analgesics on ≥10 days/month
     2. Simple analgesics on ≥15 days/month
     3. Any combination of ergotamine, triptans, simple analgesics, NSAIDs, and/or opioids on ≥10 days/month without overuse of any single drug class alone

  3. Not better accounted for by another ICHD-3 diagnosis

  To prevent MOH, it is important to counsel a patient to limit acute headache medication use. The patient needs to adhere to the following acute medication restrictions. Note that days/month restrictions refer to consecutive or nonconsecutive days:

  • ≤14 days/month of NSAIDs, aspirin, or acetaminophen
  • ≤9 days/month of combination analgesics (e.g., aspirin/acetaminophen/caffeine, triptans, ergot derivatives OR opioids

  Different medication classes can be combined on a given day. For example, a patient may combine over-the-counter combination analgesics (e.g., aspirin/acetaminophen/caffeine) and a triptan on the same day as long as he or she adheres to the dose restrictions for each agent. However, a patient should not take triptans for 8 days and also take aspirin/acetaminophen/caffeine for 10 days, as this would equal 18 days and exceed the recommended limitation of ≤9 days/month of combination analgesics, triptans, ergot derivatives, OR opiates.

  Butalbital-containing analgesics (e.g., butalbital/acetaminophen/caffeine, butalbital/aspirin/caffeine) and opioids should be avoided for recurrent headache disorders because of their associated risks of: medication-overuse headache, dependence or addiction syndromes, chronification of migraine, and heightened sensitivity to pain.

  In the setting of medication overuse, migraine preventives may be less effective or even ineffective.

Goals of migraine prevention

• Decrease episode frequency, severity, and duration
• Improve responsiveness to treatment of acute attacks
• Improve function and decrease disability
• Decrease cost of migraine management

Realistic expectations should be discussed ahead of time to prevent frustration. Prevention is considered successful if headache frequency is decreased by ≥50% following a 3-6 month treatment trial.

Continue preventive agent

While no guidelines exist, it is good practice to discuss tapering or discontinuing a preventive agent after ~1 year of “good” migraine control.

However, a patient who previously had frequent disabling episodes and has found a successful preventive agent may choose to continue prevention for a longer period of time or sometimes indefinitely.