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Am Fam Physician. 2003;67(6):1375-1378

Migraine headaches, often undiagnosed or undertreated, are a disabling problem for many persons. This chronic condition more commonly affects women than men and presents with acute attacks and variable symptoms, even when the attacks are recurrences in the same patient. Migraine is actually a syndrome, with a range of neurologic and non-neurologic characteristics. Snow and associates developed guidelines for pharmacologic management of migraine under the sponsorship of the American Academy of Family Physicians and the American College of Physicians–American Society of Internal Medicine, with help from the American Headache Society.

Treatment of acute migraine attacks is aimed at relieving symptoms rapidly to avoid headache recurrence, restoring the patient’s functionality, and minimizing the use of rescue medicines. Physicians also need to educate patients about treatment options and help them establish realistic expectations. Patients should be encouraged to identify and avoid triggers (see Table 1) and to monitor their own response to interventions.

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Nonsteroidal anti-inflammatory drugs (NSAIDs) are useful first-line agents for migraine treatment because of their tolerability and efficacy for all migraine attacks. The best evidence of efficacy exists for aspirin, ibuprofen, naproxen sodium, tolfenamic acid, and the combination of aspirin, acetaminophen, and caffeine. Acetaminophen alone is not useful.

Serotonin1B/1D agonists (triptans), used orally, intranasally, or by subcutaneous injection, are effective in migraine management. Chest symptoms can occur with the use of triptans, but true ischemic events are rare. Contraindications include risk of heart disease, basilar or hemiplegic migraine, or uncontrolled hypertension. Intranasal dihydroergotamine may be useful; the efficacy of intravenous preparations is less clear. Of the opioid preparations, only butorphanol nasal spray has been demonstrated to be efficacious. Few other data support the use of opioids; these drugs are probably best left for use in patients who have failed other treatments. Intravenous metoclopramide may be useful when the migraine syndrome includes nausea and vomiting. Intravenous corticosteroids and intranasal lidocaine are not effective.

The choice of therapy depends on the characteristics and frequency of attacks and the specific symptoms present. Patient response and coexisting illnesses also should be considered. Acute therapy should be limited to twice a week to decrease the likelihood of medication-overuse headache. Preventive therapy should be used more aggressively in patients at risk for medication overuse. Rebound headache is specifically associated with medication withdrawal. A rescue medication is useful when treatment fails and often includes an opioid preparation.

Indications for the prevention of migraine include (1) two or more seriously disabling attacks each month; (2) failure of, or contra-indication to, acute treatment; (3) the use of abortive medicine more than twice a week; and (4) occurrence of an uncommon migraine such as hemiplegic migraine or migrainous infarction.

A wide variety of preventive treatments are available. Beta blockers such as propranolol (80 to 240 mg per day) or timolol (20 to 30 mg per day) have documented efficacy in migraine prevention. Adverse effects include fatigue, depression, nausea, dizziness, and insomnia. Amitriptyline is useful in dosages of 30 to 150 mg per day; adverse effects such as drowsiness, weight gain, and anticholinergic symptoms occur with some frequency.

Limited evidence supports the efficacy of fluoxetine at dosages from 20 mg every other day to 40 mg per day. Among the anticonvulsants, the best evidence supports the efficacy of divalproex sodium (500 to 1,500 mg per day) and sodium valproate (800 to 1,500 mg per day), especially in patients with prolonged or atypical migraine aura. Many NSAIDs have documented preventive efficacy, but side effects occur in as many as 45 percent of patients. Serotonergic agents, including dihydroergotamine and methysergide, have confirmed preventive efficacy, but the latter has reported adverse effects, including retroperitoneal fibrosis and gastrointestinal symptoms. Little evidence supports the use of calcium channel blockers or alpha2 agonists. Trials of hormone therapy, feverfew, magnesium, and riboflavin are inadequate or flawed.

The authors conclude that there are successful first- and second-line treatments for migraine. When a preventive agent is used, a low dosage should be started with slow upward titration. After the patient is stable for a long time, preventive agents can be tapered or stopped.

A summary of the authors’ recommendations for migraine management is presented in Table 2.

In most patients with migraine, NSAIDs are the first-line therapy.
In patients whose migraine does not respond to NSAIDs, use migraine-specific agents (i.e., triptans, dihydroergotamine).
If nausea and vomiting are significant symptoms of an attack, use a non-oral route of medicine administration and provide an antiemetic.
Patients with migraine should be evaluated for preventive therapy.
Recommended first-line prophylactic agents are propranolol, timolol, amitriptyline, divalproex sodium, and sodium valproate.

editor’s note: Although migraine headaches occur in both men and women, women are most frequently affected. This observation has encouraged research into the influence of hormones on migraine pain pathways. The burden of migraine includes suffering and disability because only a few migraineurs are actually receiving state-of-the-art treatment. Migraine should have a more important place in the arena of women’s health. Physicians also should more thoroughly evaluate and manage their patients’ migraine headaches, keeping in mind the patient’s preferences, compliance, and clinical need. The Migraine Disability Assessment Scale (MIDAS) is useful to measure effectiveness of therapy, facilitate communication between physician and patient, and help patients understand the impact of migraine on their lives.—r.s.

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