KISS: Management of Migraine

Based on: NEJM2017;377;553  SIGN 155, 2018  BASH 2019

Triggers/exacerbating factors: 

• Many potential triggers but evidence for trigger avoidance limited
• Review medications that may be contributory:
• Oestrogen containing contraceptives, PPIs, SSRIs have been associated
• Review acute medication use - 2/3 chronic migraine sufferers have evidence of medication overuse; if taking acute medications on ≥2 days/week at risk of medication overuse headache

Acute treatment:

• Take a flexible approach depending on severity; options include:
• Aspirin 900mg, other NSAID (e.g. ibuprofen 400-600mg); adding anti-emetics (e.g. prochlorperazine 10mg, metoclopramide 10mg) improves effectiveness even in the absence of nausea and vomiting (improves gastric motility/drug absorption)
• Triptans:
• Lack of effect at 2 hours = treatment failure; lack of response to one triptan does not predict response to other triptans so try alternatives (or different delivery mode) if 2 treatment failures 
• Combining long-acting NSAID (e.g. naproxen) with triptan is more effective than triptan monotherapy
• Take early in the HEADACHE phase, not the aura phase
• Do NOT use opioids - generally ineffective and high risk of medication overuse headache

Prophylaxis:

• Consider preventative treatment if ≥ 4 migraines/month, but take a flexible approach depending on both severity as well as the frequency of attacks, as well considering individualised treatment depending on co-morbidities (e.g. amitriptyline if insomnia etc.)
• Titrate slowly to maximum effective tolerated dose for minimum 6-8 weeks before deciding on effectiveness (ideally with headache diary)
• Consider gradual withdrawal after 6-12 months of effective treatment.
• Recommended drug treatments:
• Propranolol 10-20mg BD, up to max 120-240mg/day
  
• Amitriptyline 10-150mg ON
• Topiramate 25mg OD to max 100mg BD
• Candesartan 2mg OD to max 8mg BD
• NICE (TA 631 June 2020) have recently approved fremanezumab as an option for people with chronic migraine AND when at least 3 preventive drug treatments have failed
• There is also evidence for other drugs including lisinopril, sodium valproate and other beta-blockers (metoprolol, timolol, atenolol); Note that gabapentin is NOT effective and should not be offered
• Supplements: Co-enzyme Q10 (150mg/day), Magnesium (400-600mg/day), Riboflavin (400mg/day)
  
• Non-drug treatment:
• Acupuncture (10 sessions) is recommended as an option (including by NICE)
• CBT added to drug therapy can reduce migraine-associated disability
• Menstrual migraine: 
• Consider short term preventative strategy - Zolmitriptan 2.5mg BD/TDS or frovatriptan 2.5mg BD for 2 days before until 3 days after bleeding starts

Patient information NHS Choices: Migraine triggers and Migraine Trust, Coping with migraine