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Treatment recommendations for migraine

Abstract

The pharmacological treatment of migraine can be acute or preventive. Acute treatment attempts to stop the progression of an attack or relieve pain and functional impairment once an attack has begun, whereas preventive therapy is given to reduce attack frequency and severity. Additional benefits of preventive therapy include improving responsiveness to acute attack treatment, and reducing disability. Treatment protocols should also include education and reassurance, avoidance of triggers, nonpharmacological treatments, and physical and/or complementary medicine when appropriate. The treatment plan should be reassessed at regular intervals. Acute attack medication can be specific or nonspecific, and needs to be tailored to the individual patient. Backup and rescue medication should be available in case the initial treatment fails. The route of drug administration depends on attack severity, how rapidly the attack escalates, the patient's preference, the presence or absence of severe nausea or vomiting, and the need for rapid relief. Preventive migraine treatments include β-blockers, antidepressants, calcium channel antagonists, 5-hydroxytryptamine antagonists, anticonvulsants, and NSAIDs. Preventive treatments are selected on the basis of the drugs' side-effect profiles and the patient's coexistent and comorbid conditions.

Key Points

  • Migraine treatment begins with making a diagnosis, ruling out alternative causes, ordering appropriate studies, and addressing the headache's impact

  • Acute treatment attempts to relieve the pain once an attack has begun

  • Nonspecific acute headache medications include analgesics, antiemetics, opioids, corticosteroids and dopamine antagonists, and specific acute headache medications include ergotamine, dihydroergotamine and the triptans

  • Preventive therapy is given to reduce attack frequency and severity

  • Preventive migraine treatments include β-blockers, antidepressants, calcium channel antagonists, 5-hydroxytryptamine antagonists, anticonvulsants and NSAIDs

  • The choice of preventive treatment is made on the basis of the adverse-effect profiles of the drugs and the patient's coexistent and comorbid conditions

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Figure 1: Preventive therapies for migraine.

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Competing interests

SD Silberstein is on the advisory panel or speakers' bureau, or serves as a consultant for Allergan, AstraZeneca, Endo Pharmaceuticals, GlaxoSmithKline, Medtronic, Merck, Ortho-McNeil, Pfizer, Pozen and Valeant Pharmaceuticals. He receives research support from Abbott, Advanced Bionics, Advanced NeuroModulation Systems, AGA, Allergan, AstraZeneca, Endo Pharmaceuticals, Lilly, GlaxoSmithKline, Medtronic, Merck, OrthoMcNeil, Pfizer, Pozen, ProEthic, Valeant Pharmaceuticals and Vernalis.

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Silberstein, S. Treatment recommendations for migraine. Nat Rev Neurol 4, 482–489 (2008). https://doi.org/10.1038/ncpneuro0861

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