Guidelines for management of Headache disorders
Migraine management
Tiba Specialized Hospital
Dr/ Mustafa M Hashem
ICHD-3 Diagnostic Criteria for Migraine Without Aura
Migraine without aura
A At least five attacks, fulfilling criteria B-D
B Headache attacks lasting 4-72 hours (untreated or unsuccessfully
treated)c,d
C Headache has at least two of the following four characteristics:
1 Unilateral location
2 Pulsating quality
3 Moderate or severe pain intensity
4 Aggravation by or causing avoidance of routine physical activity (eg,
walking or climbing
stairs)
D During headache at least one of the following:
1 Nausea and/or vomiting
2 Photophobia and phonophobia
E Not better accounted for by another ICHD-3 diagnosis
ICHD-3 = International Classification of Headache Disorders, Third Edition.
ICHD-3 Diagnostic Criteria for Migraine With Aura and Migraine
With Typical Aura
Migraine with aura
A At least two attacks fulfilling criteria B and C
B One or more of the following fully reversible aura symptoms:
1 Visual
2 Sensory
3 Speech and/or language
4 Motor
5 Brainstem
6 Retinal
C At least three of the following six characteristics:
1 At least one aura symptom spreads gradually over ≥5 minutes
2 Two or more aura symptoms occur in succession
3 Each individual aura symptom lasts 5-60 minutes
4 At least one aura symptom is unilateral
5 At least one aura symptom is positive
6 The aura is accompanied, or followed within 60 minutes, by headache
D Not better accounted for by another ICHD-3 diagnosis
Migraine with typical aura
A Attacks fulfilling criteria for migraine with aura and criterion B below
B Aura with both of the following:
1 Fully reversible visual, sensory, and/or speech/language symptoms
2 No motor, brainstem, or retinal symptoms
Management of Acute Migraine:
Treatment for patients with acute migraine:
Recommendations are marked up with an (R) and good-practice points
are marked up with a (✓)
(✓) When starting acute treatment, healthcare professionals should
warn patients about the risk of developing medication-overuse
headache.
Aspirin
(R) Aspirin (900 mg) is recommended as first-line treatment for
patients with acute migraine
(✓) Aspirin, in doses for migraine, is not an analgesic of choice
during pregnancy and should not be used in the third trimester of
pregnancy.
Non-steroidal Anti-inflammatory Drugs
(R) Ibuprofen (400 mg) is recommended as first-line treatment for
patients with acute migraine. If ineffective, the dose should be
increased to 600 mg.
Paracetamol
(R) Paracetamol (1000 mg) can be considered for treatment of
patients with acute migraine who are unable to take other acute
therapies
Due to its safety profile, paracetamol is first choice for the
short-term relief of mild-to-moderate headache during any
trimester of pregnancy. (✓)
Antiemetics
(R) Metoclopramide (10 mg) or prochlorperazine (10 mg) can be
considered in the treatment of headache in patients with acute
migraine. They can be used either as an oral or parenteral
formulation depending on presentation and setting
(R) Metoclopramide (10 mg) or prochlorperazine (10 mg) should
be considered for patients presenting with migraine-associated
symptoms of nausea or vomiting. They can be used either as an
oral or parenteral formulation depending on presentation and
setting
(✓) Metoclopramide should not be used regularly due to the risk of
extrapyramidal side effects.
Triptans
(R) Triptans are recommended as first-line treatment for patients
with acute migraine. The first choice is sumatriptan (50–100 mg),
but others should be offered if sumatriptan fails
(R) In patients with severe acute migraine or early vomiting, nasal
zolmitriptan or subcutaneous sumatriptan should be considered
(R) Triptans are recommended for the treatment of patients with
acute migraine associated with menstruation
(R) Sumatriptan can be considered for treatment of acute migraine
in pregnant women in all stages of pregnancy. The risks associated
with use should be discussed before commencing treatment.
Combination Therapies
(R) Combination therapy using sumatriptan (50–85 mg) and
naproxen (500 mg) should be considered for the treatment of
patients with acute migraine.
Pharmacological Prevention:
Beta Blockers
(R) Propranolol (80–160 mg daily) is recommended as a first-line
prophylactic treatment for patients with episodic or chronic
migraine.
Topiramate
(R) Topiramate (50–100 mg daily) is recommended as a
prophylactic treatment for patients with episodic or chronic
migraine
(R) Before commencing treatment women should be informed of:
o the risks associated with taking topiramate during pregnancy
o the risk that potentially harmful exposure to topiramate may
occur before a women is aware she is pregnant
o the need to use highly-effective contraception
o the need to seek further advice on migraine prophylaxis if
pregnant or planning a pregnancy.
Tricyclic Antidepressants
(R) Amitriptyline (25–150 mg at night) should be considered as a
prophylactic treatment for patients with episodic or chronic
migraine
(R) In patients who cannot tolerate amitriptyline a less sedating
tricyclic antidepressant should be considered.
Candesartan
(R) Candesartan (16 mg daily) can be considered as a prophylactic
treatment for patients with episodic or chronic migraine
(R) Use of candesartan should be avoided during pregnancy and
breastfeeding. Women using candesartan who are planning to
become pregnant, or who are pregnant, should seek advice from
their healthcare professional on switching to another therapy.
Sodium Valproate
(R) Sodium valproate (400–1500 mg daily) can be considered as a
prophylactic treatment for patients over the age of 55 with episodic
or chronic migraine
(R) Although valproate is not recommended for those under the
age of 55, for those who remain on it and who fulfil Medicines and
Healthcare products Regulatory Agency (MHRA) requirements,
the safety advice is to inform the patient of the risks to children
exposed to valproate in utero and the need to use effective
contraception
(R) If prescribing sodium valproate, check the MHRA website for
current advice
at [Link]/government/organisations/medicines-and-
healthcare-products-regulatory-agency.
Calcium Channel Blockers
(R) Flunarizine (10 mg daily) should be considered as a
prophylactic treatment for patients with episodic or chronic
migraine
(R) Use of flunarazine should be avoided during pregnancy and
breastfeeding. Women using flunarazine who are planning to
become pregnant, or who are pregnant, should seek advice from
their healthcare professional on switching to another therapy.
Gabapentin and Pregabalin
There is a lack of evidence on the use of pregabalin in patients with
episodic migraine
(R) Gabapentin should not be considered as a prophylactic
treatment for patients with episodic or chronic migraine.
Botulinum Toxin A
(R) Botulinum toxin A is not recommended for the prophylactic
treatment of patients with episodic migraine
(R) Botulinum toxin A is recommended for the prophylactic
treatment of patients with chronic migraine where medication
overuse has been addressed and patients have been appropriately
treated with three or more oral migraine prophylactic treatments
(✓) Botulinum toxin A should only be administered by
appropriately trained individuals under the supervision of a
headache clinic or the local neurology service.
Calcitonin-gene-related Peptide Monoclonal Antibodies
(R) Erenumab, fremanezumab, galcanezumab, and eptinezumab
are recommended for the prophylactic treatment of patients with
chronic migraine where medication overuse has been addressed
and patients have not benefitted from appropriate trials of three or
more oral migraine prophylactic treatments
(R) Fremanezumab, galcanezumab, and eptinezumab can be
considered for the prophylactic treatment of patients with episodic
migraine where medication overuse has been addressed and
patients have not benefitted from appropriate trials of three or more
oral migraine prophylactic treatments
(✓) Use of calcitonin-gene-related peptide (CGRP) monoclonal
antibodies should only be initiated following consultation with a
neurologist or headache specialist
(✓) There should be careful consideration of potential risks and
benefits to patients at high risk of ischaemic cardiovascular disease
before prescribing CGRP monoclonal antibodies
(✓) Use of CGRP monoclonal antibodies should be avoided during
pregnancy and breastfeeding. A washout period of 6 months is
advised before trying for a pregnancy
(✓) Medication-overuse headache should be addressed before
treatment with CGRPs. However, in patients where treatment of
medication-overuse headache has been unsuccessful, CGRP
monoclonal antibodies should still be considered.
Menstrual Migraine Prophylaxis
(R) Frovatriptan (2.5 mg twice daily) should be considered as a
prophylactic treatment in women with perimenstrual migraine from
two days before until three days after bleeding starts
(R) Zolmitriptan (2.5 mg three times daily) or naratriptan (2.5 mg
twice daily) can be considered as alternatives to frovatriptan as
prophylactic treatment in women with perimenstrual migraine from
2 days before until 3 days after bleeding starts
(✓) Women with menstrual-related migraine who are using triptans
at other times of the month should be advised that additional
perimenstrual prophylaxis increases the risk of developing
medication overuse headache.
Algorithm 1: Pharmacological Management of Patients with
Migraine—Treatment Pathway
