The American Academy of Family Physicians (AAFP) and the American College of Physicians–American Society of Internal Medicine (ACP-ASIM), working jointly and with assistance from the American Headache Society, recently developed guidelines for primary care physicians on the pharmacologic management of acute migraine attacks and the prevention of migraines. The clinical guidelines were in the November 19, 2002, issue of Annals of Internal Medicine. The guidelines were based on articles by Matchar and associates and Ramadan and colleagues (available atwww.aan.com/professionals/practice/guidelines.cfm) but contain somewhat different recommendations based on the levels of evidence needed to make a positive recommendation.
Diagnosis and Initial Management
Migraine is a primary headache disorder with a wide variety of manifestations. Recurrent acute attacks may not have the same characteristics in all patients or even in the same patient. Criteria for the diagnosis of migraine have been developed by the International Headache Society. However, physicians need to be aware that a patient can have more than one headache disorder (e.g., migraine and episodic tension-type headaches).
Patient Education and Involvement
Recommendation. The patient should be educated about the control of acute migraine attacks and preventive treatment. The patient should be involved in formulating a management plan. Regular reevaluation of therapy is important.
A discussion of the benefits and adverse effects of therapeutic options can help the patient establish realistic expectations. Together, the physician and patient should decide how acute attacks are to be treated and whether the patient would benefit from preventive medication.
Patient input is crucial to treatment selection and evaluation. Tracking progress with a daily flow sheet can be helpful in assessing treatment. The patient's headache diary should include the severity, frequency, and duration of migraine attacks; the degree of disability resulting from the attacks; the response to treatment; and adverse effects from medication. The patient also should be encouraged to identify factors or situations that trigger migraines (e.g., alcohol, caffeine, foods containing tyramine or nitrates, stress, fatigue, perfumes, fumes, glare, flickering lights).
Management of Acute Attacks
Management of acute migraine attacks needs to be individualized. Factors to consider include associated symptoms (e.g., nausea, vomiting), the frequency and severity of the attacks, and the degree of disability caused by the attacks. Comorbid conditions (e.g., uncontrolled hypertension, heart disease, pregnancy) and previous responses to specific medications may limit treatment options.
To guard against medication-overuse headaches, experts suggest limiting the use of acute treatment to no more than twice a week. Preventive migraine therapy should be considered if medication overuse is suspected or considered to be a risk.
Consideration should be given to the possibility of rebound headaches, which are associated with the withdrawal of analgesic drugs or abortive migraine medications. Although universal agreement is lacking, it is generally thought that rebound headaches can be caused by opiates, triptans, ergotamine, and analgesic medications that contain caffeine, isometheptene, or butalbital.
The physician may need to consider the patient's use of a rescue medicine (e.g., an opioid, a compound that contains butalbital) at home when other treatments for severe migraine attacks are not successful. Appropriate situations for use should be addressed.
Recommendation. In most patients with migraine, non-steroidal anti-inflammatory drugs (NSAIDs) are first-line treatment.
Evidence for efficacy is most consistent for these agents: aspirin, ibuprofen, naproxen sodium, tolfenamic acid (not currently available in the United States), and the acetaminophen-aspirin-caffeine combination. Acetaminophen alone is ineffective.
Recommendation. Migraine-specific agents (triptans, dihydroergotamine [DHE]) should be used in patients whose migraine attacks do not respond to NSAIDs.
Evidence for efficacy is good for the following triptans (serotonin1B/1D agonists): orally administered naratriptan, rizatriptan, and zolmitriptan, and orally and subcutaneously administered sumatriptan. Triptans should not be used in a patient who has uncontrolled hypertension or basilar or hemiplegic migraine or who is at risk for heart disease.
Evidence for efficacy and safety is good for intranasally administered DHE. There also is good evidence for the efficacy of butorphanol nasal spray. Treatment with opioids may be considered if other medications cannot be used and if the risk of abuse has been addressed and sedation is not a concern.
Recommendation. A nonoral route of administration should be selected when nausea or vomiting present early as significant components of migraine attacks. Nausea should be treated with an antiemetic drug.
Numerous medications with varying efficacies are used to prevent migraines (www.annals.org). Nonpharmacologic therapies also are used (www.aan.com/professionals/practice/guidelines.cfm).
The AAFP/ACP-ASIM recommendations and the U.S. Headache Consortium recommendations are compared in the accompanying table.
Recommendation. The patient with migraine should be evaluated for the use of preventive treatment.
Commonly accepted indications for migraine prevention are as follows: two or more migraine attacks per month, with the attacks producing disability for three or more days per month; use of rescue medication more than twice a week; failure of acute treatments or contraindications for such treatments; or the presence of uncommon migraine conditions (e.g., prolonged aura, migrainous infarction, hemiplegic migraine). Additional factors that need to be considered include the patient's preference, adverse events with treatments for acute migraine attacks, and how much treatment costs for acute attacks and migraine prevention.
Recommendation. First-line agents for the prevention of migraines are as follows: propranolol, 80 to 240 mg per day; timolol, 20 to 30 mg per day; amitriptyline, 30 to 150 mg per day; divalproex sodium, 500 to 1,500 mg per day; and sodium valproate, 800 to 1,500 mg per day.
Some other drugs have been shown to be efficacious, but data on associated adverse events are limited. These agents include methysergide and a number of agents that currently are not available in the United States, including flunarizine, lisuride, pizotifen, and time-released DHE.
There is good evidence for the efficacy of propranolol and timolol. Common adverse effects of beta blockers, including dizziness, nausea, fatigue, depression, and insomnia, appear to be tolerated fairly well.
One comparative trial suggested that propranolol is superior in the patient with migraine alone, but that amitriptyline is more effective in the patient with mixed migraine and tension-type headache. Tricyclic antidepressants, including amitriptyline, can cause weight gain, drowsiness, and anticholinergic symptoms.
Evidence for efficacy is good for divalproex sodium and sodium valproate. These agents may be particularly effective in the patient who has prolonged or atypical migraine aura. Adverse effects can include hair loss, tremor, weight gain, and teratogenic effects (e.g., neural tube defects).
Once a drug for migraine prevention has been chosen, treatment should be initiated with a low dose. The dose should be increased slowly until benefits are achieved without adverse effects or are limited by adverse events. An adequate trial of the drug is important because clinical benefits may not become apparent for two to three months. After a period of stability, consideration can be given to tapering or discontinuing the drug.