Patients with acute migraines should assess their condition before starting a treatment regimen.
Investigators discuss the diagnosis and acute management of migraine in a recent article published in the Canadian Medical Association Journal (CMAJ). According to investigators, migraine treatment should offer fast headache pain and related symptom relief, prevent recurrent symptoms, and restore patient function.
“Ideally, treatment should be self-administered, effective, well tolerated and affordable, and require minimal redosing,” wrote study authors in the article.
In 2019, migraines were considered the number 1 cause of disability among women aged 15 to 49 years, affecting 3-times as many women as men (18% and 6%, respectively). Migraines were considered the number 2 leading cause of disability among men and women of any age group worldwide.
Migraine attacks can include 5 different phases called prodrome, aura, headache, postdrome and interictal, although many patients do not experience every phase in this exact order. Migraines can be further placed into 6 categories: migraine without aura, migraine with aura, chronic migraine, complications of migraine, probable migraine, and episodic syndromes that may be associated with migraine. Patients often experience different headache phenotypes.
Migraines can be screened or scanned for using imaging, however experts do not recommend routine imaging without the presence of red flags or abnormalities in a neurologic examination. They believe that imaging can lead to incidental findings that trigger patient anxiety and unnecessary investigations.
Investigators reviewed original articles and clinical practice guidelines published in 2021 to understand diagnosis and drugs used for effective management. Based on their research, experts recommend taking a stratified approach to treating acute migraines, encouraging patients to consider different treatment options and/or combine different classes of medications.
They further recommend that patients learn to assess their level of functional impairment during a migraine. Doing so may guide them to base their decisions on a strategized treatment plan.
The authors also recommend the “start low and go slow” method when choosing an oral prevention medication. The team recommends that patients and practitioners account for comorbidities that can inhibit the efficacy of the migraine medication.
“Guidelines from the Canadian Headache Society and American Headache Society both indicate that acetaminophen, acetylsalicylic acid, diclofenac, ibuprofen, naproxen sodium, and triptans have the highest level of evidence for treatment of migraine attacks,” wrote the authors.
While triptans are considered a mainstay treatment for acute migraines, they are contraindicated in many patients, especially those with cardiovascular disease (CV). Fortunately, the FDA approved ditans and gepants—2 orally administered small-molecule drugs—to treat acute migraine attacks. Evaluated in phase 3, randomized, placebo-controlled trials, they are considered safe and effective for patients with CV.
However, patients are cautioned against routine use of dihydroergotamine because of risk of adverse events (AEs). Further, the Canadian Headache Society cautions against routine use of combination analgesics with codeine or tramadol, opioids, and butalbital-containing medications as well, and suggests that at-risk patients be screened for medication overuse.
“Older medications remain effective, although newer medications may be preferred for certain groups of patients,” wrote authors in the article.
Tzankova V, Becker W, Chan T. Diagnosis and acute management of migraine. CMAJ. 2023;195(4):E153-E158. doi:10.1503/cmaj.211969