Introduction
Migraine is the most common headache condition prompting a visit to the physician’s office. They are recurring headaches that are unilateral, pulsating, moderate to severe, aggravated by routine physical activities, and are associated with nausea and/or photophobia and phonophobia. When these are associated with fully reversible, gradually occurring, neurologic symptoms such as visual changes, it is diagnosed as migraine with aura. Migraine without aura is more common than migraine with aura, and many patients have both types. Chronic migraine is diagnosed when there are 15 or more headache days per month.
Challenges
There are overlaps between various headache disorders, and some patients may present with multiple headache disorders or even a combination of primary and secondary headaches. Migraine aura can also mimic transient ischemic attacks (TIAs). In addition, migraine is comorbid with multiple psychiatric (eg, depression, post-traumatic stress disorder) and medical conditions (eg, stroke, epilepsy). Patient history need to be carefully explored to ensure accurate diagnosis and appropriate treatment.
Overuse of acute pain medications is common. In addition, migraine patients may be taking opioids to treat other pain conditions. Medication weans are often required for the treatment of migraine.
Pregnant patients: Many patients report improvement of their migraine when they are pregnant, but some report worsening of the migraine. Most migraine medications have not been extensively studied in pregnant populations, and their continued use require candid discussions between the patient and the provider.
Treatment Recommendations
When to order brain imaging?
- There are currently no imaging diagnostic criteria for migraine. MRI of the brain can help with the diagnosis of secondary headache disorders in the cases of patients presenting with abnormal neurologic exams or a new headache type, new onset headache in the elderly, or headache with large positional component.
Which abortive medication to choose?
- If the patient does not have a history of vascular disease or severe hypertension, a triptan medication should be tried. Triptans vary in efficacy, formulation, and side-effect profile, and selection should be based on patient preference as well as the characteristic of the headaches.
When to add a preventive medication?
- If patients have more than 2 headache days per week, he/she may benefit from preventive medications. Some common preventive medications include propranolol, topiramate, tricyclic antidepressants, riboflavin, CoQ10, and magnesium citrate. Newer calcitonin-gene related peptide (CGRP) antagonists can also be used.
Other than medications, an individualized multimodal treatment plan should be developed for each chronic migraine patient. These may include nutritional changes, supplements, exercise, sleep training, pain psychology, neuromodulation devices, and interventional techniques such as botox injections and occipital nerve blocks.
Third edition of the International Classification of Headache Disorders (ICHD-3). https://ichd-3.org/ Cephalalgia 2018, Vol. 38(1) 1–211
Dodick DW. Migraine. Lancet. 2018 Mar 31;391(10127):1315-1330. doi: 10.1016/S0140-6736(18)30478-1. Epub 2018 Mar 6. PMID: 29523342.
Cameron C, Kelly S, Hsieh SC, Murphy M, Chen L, Kotb A, Peterson J, Coyle D, Skidmore B, Gomes T, Clifford T, Wells G. Triptans in the Acute Treatment of Migraine: A Systematic Review and Network Meta-Analysis. Headache. 2015 Jul-Aug;55 Suppl 4:221-35. doi: 10.1111/head.12601. Epub 2015 Jul 14. PMID: 26178694.
Puledda F, Goadsby PJ. An Update on Non-Pharmacological Neuromodulation for the Acute and Preventive Treatment of Migraine. Headache. 2017 Apr;57(4):685-691. doi: 10.1111/head.13069. Epub 2017 Mar 13. PMID: 28295242.
Ashina M. Migraine. N Engl J Med. 2020 Nov 5;383(19):1866-1876. doi: 10.1056/NEJMra1915327. PMID: 33211930.