Migraine Management (eTG)

✨ General Treatment Principles

• Initiate acute treatment at the onset of migraine symptoms for best efficacy.
• Aura symptoms are not alleviated by acute pharmacotherapy.
• Use non-opioid analgesics (NSAIDs, paracetamol) as first-line for acute attacks.
• Triptans are second-line if response to non-opioids is inadequate.
• Opioids should generally be avoided; reserve for cases where other options are contraindicated and under specialist advice.
• Avoid medication overuse:
  • NSAIDs/non-opioid analgesics: Limit to <15 days/month
  • Triptans and combination medications: Limit to <10 days/month
• Frequent use of acute therapy (>2–4 days/month) should prompt consideration of preventive therapy.

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✨Lifestyle Measures, Physiotherapy & Complementary Therapies

Lifestyle and Behavioural Recommendations:

• Maintain regular sleep patterns and avoid oversleeping or sleep deprivation.
• Ensure regular meals; avoid prolonged fasting or erratic eating to stabilise blood glucose.
• Maintain adequate hydration: 1.5–2 L of water daily.
• Limit caffeine intake: 1–2 caffeinated drinks per day.
• Engage in moderate aerobic exercise (30–40 min, 3–4x/week); low-impact activities like walking are preferred.
• Optimise workplace ergonomics and take regular screen breaks.
• Incorporate stress-reduction techniques:
  • Breathing exercises, progressive muscular relaxation
  • Yoga, mindfulness meditation
  • Cognitive behavioural therapy (CBT), biofeedback
• Avoid known personal triggers:
  • Foods: MSG, chocolate, citrus, processed meats
  • Substances: alcohol, perfumes, smoke

Physiotherapy:

• Refer if patient has cervical tension, postural abnormalities, or limited neck range of motion.

Acupuncture:

• Cochrane review (2016): Supportive evidence for use in episodic migraine prophylaxis.
• Minimum: 6 sessions required for benefit.

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✨ Acute Non-Pharmacological Treatments

• Cold compresses to forehead or occiput (targeting supraorbital and occipital nerves).
• Warm packs to neck and shoulders to relieve associated tension.
• Neck mobilisation and stretching exercises.
• Rest in a quiet, dark room.

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✨ Acute Pharmacological Management (Adults)

• Non-Opioid Analgesics (First-line)

Drug	Dose	Max Daily Dose	Notes
Aspirin (soluble)	900–1000 mg q4–6h	4 g	Avoid in pregnancy, peptic ulcer disease
Ibuprofen	400–600 mg q4–6h	2.4 g	Anti-inflammatory and analgesic
Diclofenac potassium	50 mg q4–6h	200 mg	Rectal form if nausea is present
Naproxen	500–750 mg q4–6h	1250 mg	Slower onset but longer action
Paracetamol (soluble)	1 g q4–6h	4 g	Safer in pregnancy, less effective in severe migraine

• Antiemetics (Enhance absorption, treat nausea)

Drug	Dose	Max/24h	Caution
Metoclopramide	10 mg q6h	30 mg	Risk of extrapyramidal symptoms
Domperidone	10–20 mg q6h	30 mg	Avoid >60 yrs, QT prolongation risk
Ondansetron	4–8 mg q6h	16 mg	QTc risk at high doses
Prochlorperazine	5–10 mg q6h	30 mg	Sedation, dystonia risk

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✨ Triptans for Moderate-Severe Attacks

• Use if non-opioid analgesic (with or without antiemetic) is ineffective.
• Choose based on onset of action, tolerability, dosage form, and cost.
• Avoid ergotamines within 24 hours of triptan use.
• Combination with NSAID (e.g. sumatriptan + naproxen) may improve efficacy.

Drug	Route	Dose	Re-dose Interval	Max/24h
Eletriptan	Oral	40–80 mg	≥2 hr	160 mg
Naratriptan	Oral	2.5 mg	≥4 hr	5 mg
Rizatriptan	Oral	10 mg	≥2 hr	30 mg
Sumatriptan	Intranasal	20 mg	≥2 hr	40 mg
Sumatriptan	Oral	50–100 mg	≥2 hr	300 mg
Zolmitriptan	Oral	2.5 mg (→5 mg if ineffective)	≥2 hr	10 mg
Sumatriptan	Subcut	6 mg	≥1 hr	12 mg

• If no benefit with first dose, do not repeat in same attack.
• Safe with SSRI/SNRI, but counsel on serotonin syndrome symptoms.

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✨ Migraine in Pregnancy

Exclude secondary causes:

• Pre-eclampsia, PRES, HELLP, CVST, pituitary apoplexy

Safe First-line:

• Paracetamol (soluble): 1 g q4–6h (max 4 g)
• Metoclopramide: antiemetic of choice

If unresponsive:

• Codeine (sparingly): avoid in breastfeeding or CYP2D6 ultrarapid metabolisers
• Sumatriptan (occasional use): preferred triptan
• IV therapy for refractory migraine:
  • Rehydration with NaCl 0.9%
  • Magnesium sulfate IV (short-term only)
  • Prednisone/prednisolone 50 mg OD for 2 days

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✨Intractable Migraine (Status Migrainosus)

• Defined: >72 hours continuous migraine despite treatment

Stepwise Hospital Treatment:

1. Rehydrate + IV antiemetic (e.g. ondansetron)
2. Sumatriptan 6 mg SC (if no triptan in prior 2 hrs)
3. Ketorolac 30 mg IM (if no NSAID in past 4–6 hrs)
4. If unresponsive:
   • ECG, check K+ and Mg2+
   • Pretreat with NaCl 0.9% 500 mL IV
   • Administer chlorpromazine 12.5 mg IV in 100 mL NaCl 0.9% over 30 min
   • Repeat x2 (total 37.5 mg); monitor BP q30 min
   • If dystonia: benzatropine 1–2 mg IV
5. Alternative: IV dexamethasone 12–20 mg, repeat in 12 hrs if needed
6. Last-line: dihydroergotamine (only if no triptan in last 24 hrs)
7. Lidocaine IV: ICU/monitored setting only

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✨ MIGRAINE PROPHYLAXIS – CLINICAL OVERVIEW

🔸 Indications for Prophylaxis

• ≥2 migraine attacks/month requiring acute treatment
• Disabling or prolonged migraines
• Frequent use of triptans or analgesics (>10 and >15 days/month respectively)
• Refractory or recurrent status migrainosus
• Patient preference to reduce acute medication use

FACTORS GUIDING DRUG SELECTION

Table: Drug Choice by Comorbidity

Comorbidity	Drugs to Consider	Drugs to Avoid
Insomnia	TCAs (e.g. amitriptyline), pregabalin, gabapentin	–
Anxiety / POTS	Propranolol	–
Obesity / Diabetes	Candesartan, topiramate	Sodium valproate, pizotifen
Fibromyalgia	TCAs, pregabalin	–
Neck tension / Bruxism	TCAs	–
Asthma	–	Beta-blockers (e.g. propranolol)
Renal calculi	–	Topiramate (risk of nephrolithiasis)
Depression (current or past)	SSRI, SNRI, TCA	Topiramate, beta-blockers, flunarizine (with caution)
Menopausal symptoms	Propranolol, gabapentin, SSRI	–

Note: Avoid sodium valproate in females of childbearing potential due to teratogenicity.

✨ FIRST-LINE PROPHYLACTIC AGENTS FOR ADULTS

Drug	Starting Dose	Titration	Max Dose	Key Considerations
Amitriptyline	10 mg nocte	+10 mg weekly	75 mg nocte	Sedating, good for insomnia, depression, tension headache
Nortriptyline	10 mg nocte	+10 mg weekly	75 mg nocte	Fewer anticholinergic effects than amitriptyline
Candesartan	4 mg daily	+4 mg weekly	32 mg/day	Renoprotective, good in HTN/metabolic syndrome
Propranolol	20 mg nocte	+20 mg weekly	160 mg/day (divided)	Avoid in asthma, may benefit anxiety or tremor
Topiramate	25 mg nocte	+25 mg weekly	100 mg BD	Appetite suppression, cognitive side effects, teratogenic
Sodium valproate	200 mg nocte	+200 mg weekly	500 mg BD	Avoid in women of childbearing age
Pizotifen	0.5 mg nocte	+0.5 mg weekly	1.5–3 mg nocte	Sedating, weight gain common
Verapamil SR	90 mg daily	slow titration over 3 weeks	240 mg/day	Avoid in bradycardia/heart block, requires ECG monitoring

💡 Trial each drug for 8–12 weeks at maximum tolerated dose before declaring failure.

✨ TREATMENT ALGORITHM

1. Start first-line agent based on comorbidities and side effect profile
2. Titrate gradually to max tolerated dose
3. Continue for 8–12 weeks
4. Assess efficacy: ≥50% reduction in attack frequency = success
5. If ineffective → Switch to alternative agent
6. If ≥2 agents fail → Refer for specialist input

✨ SPECIALIST-ONLY OPTIONS & REFRACTORY MIGRAINE

• Botulinum toxin A (PBS restricted to ≥15 headache days/month, ≥8 migraine days, failed ≥3 agents)
• Other drugs (limited evidence/off-label):
  • Metoprolol, atenolol
  • Clonidine, carbamazepine
  • Flunarizine (SAS only)
  • Cyproheptadine, duloxetine
• Devices:
  • External trigeminal nerve stimulator (e.g. Cefaly)

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✨PROPHYLAXIS IN PREGNANCY

General Approach

• Optimise nonpharmacological measures first
• Avoid prophylactic drugs if possible, especially in first trimester
• If required, use lowest effective dose

Safer Options

Drug	Notes
TCAs (e.g. amitriptyline)	Conflicting data but generally low risk
Propranolol	Risk of IUGR, avoid near term to prevent fetal bradycardia
Magnesium (oral)	Considered safe short-term; limit prolonged high-dose
Riboflavin, CoQ10	Likely safe but limited pregnancy data

🔴 Avoid: Sodium valproate, topiramate, flunarizine (teratogenicity)

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✨MENSTRUAL MIGRAINE – SHORT-TERM PROPHYLAXIS

Drug	Dose	Duration
Ibuprofen	400 mg TDS	5–7 days from 2–3 days pre-menses
Naproxen MR	750–1000 mg daily	As above
Naratriptan	1.25–2.5 mg BD	As above

Consider:

• Increasing regular prophylactic dose perimenstrually
• COCP continuous cycling
• Estrogen supplementation (transdermal/oral) if appropriate

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✨ MIGRAINE IN CHILDREN

Acute Treatment

Drug	Dose	Max
Ibuprofen	5–10 mg/kg	Max 30 mg/kg/day (≤2400 mg)
Paracetamol	15 mg/kg	Max 60 mg/kg/day (≤4000 mg)

⚠️ Avoid aspirin (Reye’s syndrome)

Antiemetics

Drug	Dose
Ondansetron	0.1–0.15 mg/kg (max 4–8 mg) oral/IV

🚫 Use metoclopramide/prochlorperazine with caution (dystonia risk)

Triptans (≥6 years)

Drug	Dose
Sumatriptan nasal	10–20 mg
Rizatriptan	5 mg (20–39 kg), 10 mg (≥40 kg)

Preventive Treatment

• Effective: Propranolol, flunarizine (SAS access)
• Ineffective: Pizotifen, clonidine, amitriptyline
• Conflicting: Topiramate, cyproheptadine, valproate, riboflavin
• Nonpharmacological: CBT, relaxation therapy, magnesium, acupuncture

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✨ WHEN TO REFER

• Sudden change in migraine pattern
• Prolonged aura (>60 minutes) or atypical features
• ≥10 days/month of acute medication use
• Refractory to ≥2 prophylactic agents
• Repeated ED visits or functional impairment
• Aura without headache (acephalgic migraine)
• Thunderclap headache → ED evaluation

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✨ AURA WITHOUT HEADACHE (ACEPHALGIC MIGRAINE)

• Rule out TIA, seizure
• Red flags:
  • First aura >40 years
  • Prolonged aura >60 min
  • Exclusively negative symptoms (e.g. hemianopia)
• Diagnosis supported by photophobia, nausea
• Consider prophylaxis if frequent
• Refer to neurologist

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