Acute migraine therapies should provide consistent, rapid relief and enable the patient to resume normal activities at home, school, or work.
A stratified care approach, in which the selection of initial treatment is based on headache-related disability and symptom severity, is the preferred treatment strategy for the patient with migraines.
Strict adherence to maximum daily and weekly doses of anti-migraine medications is essential.
Preventive therapy should be considered in the setting of recurring migraines that produce significant disability; frequent attacks requiring symptomatic medication more than twice per week; symptomatic therapies that are ineffective, contraindicated, or produce serious side effects; and uncommon migraine variants that cause profound disruption and/or risk of neurologic injury.
The selection of an agent for headache prophylaxis should be based on individual patient response, tolerability, convenience of the drug formulation, and coexisting conditions.
Each prophylactic medication should be given an adequate therapeutic trial (usually 6 months) to judge its maximal efficacy.
A general wellness program and consideration of headache triggers should be included in the management plan.
After an effective abortive agent and dose have been identified, subsequent treatments should begin with that same regimen.
Preclass Engaged Learning Activity
Read the following article: Vandenbussche N, Laterza D, Lisicki M, et al. Medication-overuse headache: A widely recognized entity amidst ongoing debate. J Headache Pain. 2018;19(1):50. Published July 13, 2018. doi:10.1186/s10194-018-0875-x.
Review other existing literature related to whether medication-overuse headache is a distinct entity. Summarize two key points on both the pro and con sides of the issue. Be prepared to discuss or debate in class. (Note to instructors: It would be a good opportunity to assign teams and have an in-class discussion or formal debate.)
Headache is one of the most common complaints encountered by healthcare practitioners and among the top five principal reasons adults 18 to 44 years of age visit US emergency departments.1 It can be symptomatic of a distinct pathologic process or can occur without an underlying cause. In 2013, the International Headache Society (IHS) updated its classification system and diagnostic criteria for headache disorders, cranial neuralgias, and facial pain2 (Table 78-1). Designed to facilitate headache diagnosis in clinical practice (as well as to be used for research), the IHS classification provides more precise definitions and standardized nomenclature for both the primary (migraine, tension-type, and cluster headache) and secondary (symptomatic of organic disease) headache disorders. This chapter focuses on the management of the primary headache disorders.
TABLE 78-1International Headache Society Classification System: Focus on Migraine Headache |Favorite Table|Download (.pdf) TABLE 78-1 International Headache Society Classification System: Focus on Migraine Headache
|Migraine without aura |
|Migraine with aura |
|Migraine with typical aura (lasting less than 1 hour) with or without headache |
|Migraine with brainstem aura |
|Hemiplegic migraine (familial, sporadic) |
|Retinal migraine ...|