How to Manage Migraine in the Outpatient Setting:
Lifestyle modifications are crucial!
Counseling:
-maintain a close headache diary to assess for trends, changes, and improvement
-good sleep hygiene, maintaining good sleep of 7-8 hours a night, no late meals, or caffeine after 2-3pm, no TV/phone/computers in bed or an hour before bedtime
-eat regular meals at consistent times and avoiding skipping meals, proper nutrition and balanced diet
-maintain adequate hydration (at least 2 L of non-caffeinated beverages)
-should decrease daily caffeine consumption to 200 mg per day or less (two 6oz cups)
-regular exercise - at least 30-45 minutes of cardiovascular exercise 3 days a week
-stress reduction with relaxation techniques, consider mindfulness and meditation
-avoidance of triggers to minimize attack frequency
-there is a strong link between headache and mood, advise the patient to follow up with a therapist, discuss how improved mood can lead to better headache control and vice versa (some resources include psychologytoday.com and NAMI, patients can also contact their insurance to find covered providers)
Preventive Therapies:
-Prevention medication should be initiated if patients report a headache frequency of >6-8 days a month of headache
-When choosing a preventive therapy, one should consider the patient’s other medical/psychiatric comorbidities (eg: hypertension, obesity, anxiety or depression, epilepsy, etc)
-Preventive therapies take at least 6 weeks to work, so encourage the patient to give the medication a full adequate trial and be patient!
Some Pearls on Prevention:
-If the patient has hypertension, consider candesartan or beta blockers
-If the patient is obese, consider topiramate or zonisamide
-If the patient has anxiety, consider venlafaxine
-If the patient has difficulty sleeping/insomnia, consider TCA’s or gabapentin nightly
-If the patient has neck pain/TMJ, consider gabapentin or TCA’s
-If the patient has prolonged or a complex aura, consider memantine, lamotrigine, or topiramate
-If the patient has vestibular migraine, consider topiramate or an SSRI
Acute Therapies:
-Acute therapies should be individualized and tailored to the specific patient, stratified treatment is more efficacious than stepwise treatment
-Counsel the patient to treat early as this will maximize likelihood of relief and reduced risk of recurrence (unless patient’s frequency is high)
-Remember to counsel patients use no more than 2 days a week max 10 days a month
TRIPTANS
-Triptans are the mainstay of migraine treatment
-Triptans are contraindicated in patients with a history of stroke, MI, CAD, or uncontrolled hypertension; should not be used in patients with hemiplegic migraine or migraine with brainstem aura
-If patient is over the age of 65, should risk stratify with regardings to CV disease prior to prescribing
-Fastest acting - sumatriptan injection/NS, sumatriptan PO, rizatriptan, zolmitriptan NS
-Slowest acting - naratriptan, frovatriptan
-In between - zolmitriptan PO, eletriptan, almotriptan
-Consider pairing a triptan with an NSAID or an anti-emetic (if prominent nausea) at headache onset
-Use full dose for maximum efficacy, writing for sumatriptan 25mg or 50mg PO will likely yield partial relief which can increase risk of recurrence
-Patient should be counseled to take triptan early at onset, and repeat the dose in 2hrs if no relief (no more than 2 doses in 24h period)
-Side effects to discuss: possible “triptan effect” - tingling, flushing, tightness in the jaw/neck area, warmth in the body, nausea. This is brief and temporary, tends to happen more often with the faster acting triptans. Important to discuss this ahead of time especially with anxious patients
*Triptans approved in pediatrics:
-rizatriptan for ages 6+
-zolmitriptan NS, almotriptan, treximet (sumatriptan-naproxen) for ages 12+
Other Rescue Medications:
-Anti-inflammatories - naproxen, diclofenac
-Combination analgesics - excedrin/fioricet, recommend avoiding these given has caffeine and are notorious for contributing to medication overuse headache
-Anti-emetics - metoclopramide, ondansetron
-Muscle relaxants (great for patients with neck pain, TMJ) - tizanidine, cyclobenzaprine
--Tizanidine is also a great choice for patients with MOH/frequent headaches as it carries little risk of rebound. If using daily, need to check LFT’s q6 months.
-Opiates should not be used for headache management, and patients should be counseled to reduce/avoid opiates for other indications as can lead to hyperalgesia/MOH