management of migraines

Management of migraines includes both acute and prophylactic treatments.

• For acute migraine attacks: Take early treatment while pain is mild. Use combination therapy with an oral triptan and a non-steroidal anti-inflammatory (NSAID) or paracetamol, or monotherapy with an oral triptan, NSAID, aspirin (900 mg), or paracetamol. If oral treatment is ineffective, consider non-oral formulations such as intra-nasal or subcutaneous triptans. Consider offering an anti-emetic (such as metoclopramide 10 mg or prochlorperazine 10 mg) in addition to other acute medication, even if nausea is absent. Do NOT offer ergots or opioids. Treatments not effective after 2 hours are unlikely to work in that attack, and alternative treatments should be considered ¹.
• For medication overuse headache: Stop overused acute medications for at least 1 month, preferably abruptly, and monitor for worsening symptoms and withdrawal effects. Review diagnosis and management 4–8 weeks after withdrawal ².
• Preventative (prophylactic) treatment: Consider medications such as propranolol (80–160 mg daily), topiramate (50–100 mg daily), or amitriptyline (25–75 mg at night). These should be titrated slowly over 6–8 weeks and continued for at least 6–8 weeks to assess effectiveness. Discuss realistic treatment goals, aiming for a 30–50% reduction in migraine frequency or severity. Regular review after 6 months is recommended to assess ongoing need for prophylaxis ¹.
• Non-pharmacological therapies: Consider behavioral interventions (relaxation, mindfulness, cognitive behavioral therapy), acupuncture (up to 10 sessions over 5–8 weeks), and lifestyle modifications including trigger avoidance and keeping a headache diary ¹.

Follow-up should be arranged within 2–8 weeks to monitor treatment effectiveness and adverse effects ¹.