Old toolbox on the workbench in a carpentry

Migraine Treatment Toolbox

Peter Lazzopina, M.D.

Headache is one of the most common and most troublesome diagnoses seen in the primary care clinic.  Failure to use a systematic approach to the diagnosis and treatment of headache leads to uncertainty and fear for both the patient and physician.  At Opentuyu, we advocate and teach a structured methodology for assessing headaches.  This article will share our approach to headaches and provide a toolbox for the treatment of acute and recurrent migraine in the clinic setting.

 

Most headaches seen in a clinic setting are going to be primary in nature.  Our task in diagnosing headache is to rule out life threatening or disabling causes and to classify the type of headache so that treatment can be successfully directed.

Use the mnemonic SNOOP to recall the red flags of headache1:

 

  • Systemic symptoms/illness (HIV, pregnancy, cancer, fever, etc)
  • Neurologic symptoms/signs (meningeal signs, confusion, neurologic deficits)
  • Onset sudden (thunderclap)
  • Onset recent (after age 40)
  • Progressive or prior headache was different

 

Headaches associated with a red flag should be evaluated further.  Suspected mass lesions should be assessed by MRI of the brain with and without contrast (unless contraindicated) rather than CT. Headache with fever and other neurologic symptoms will typically require lumbar puncture.

 

In addition to ruling out red flags, the chief aim of the primary care physician in his approach to headache is to successfully classify the type of headache to allow appropriate, directed treatment. The simplest method uses historical clues to categorize the headache as illustrated in the table below.

Headache Classification2

Tension Migraine Cluster
Location/Laterality Frontal, bilateral Unilateral or bilateral Unilateral: orbital/temporal
Quality Squeezing, vice-like pounding Severe, stabbing
Frequency/Duration Hours to 7 days 4-72 hours Seconds to minutes in clusters
Associated symptoms none Aura, nausea, photo/phonophobia Lacrimation, rhinorrhea, sweating
Exacerbation Triggers may be present Physical exertion
Alleviation OTC oral analgesics OTC oral analgesics

Lying down in dark room

Oxygen

Please note that there may be a mix of tension and migraine type features for some patients.  Additionally, some patients may become dependent on OTC and prescription oral analgesics and, consequently, suffer from rebound headache.  These headaches are brought on by the absence of analgesia and treatment requires supervised weaning from most oral analgesics.

 

Once migraine has been diagnosed as the primary cause of the headache, the next step is to develop an individualized treatment plan.  Acute treatment of migraine is focused on providing immediately pain relief.  Frequently, individuals will have tried a number of oral analgesics at home without relief and will require in-office treatment initially.

 

Acute Migraine Treatment

Migraines are most effectively treated by maximum indicated doses of medications rather than smaller, incremental dosing.  Furthermore, combinations of medications typically work synergistically to reduce pain.  Our approach to migraine treatment in the clinic implements both these principles

The most underrated and underutilized migraine treatment is intravenous fluids.  For various reasons volume depletion can play a role in the initiation and maintenance of migraine pain.  Generous use of intravenous volume repletion is part of the treatment protocol in most studies evaluating various medications for the treatment of migraines; it is unknown how much of the treatment effects in these studies is due to the intravenous fluids3.  Therefore, we typically administer 1-2 liters of intravenous normal saline to migraine patients in our clinic.

Magnesium has been shown to be effective for all patients who experience migraine with aura4.  Two grams administered intravenously treats pain, nausea and other associated symptoms.  In migraineurs without aura, magnesium reduces phonophobia and photophobia.  At doses utilized for migraine treatment, side effects are limited to nausea and diarrhea.  These are dose dependent and typically 2 grams of magnesium is well tolerated.

Ketorolac (Toradol) has been shown to be highly effective for migraine treatment in numerous studies3.  Due to the risk of acute kidney injury we avoid intravenous use of ketorolac in our clinic.  However, a dose of 60 mg administered intramuscularly is well tolerated and efficacious.

Antiemetics are readily available in most clinic and emergency department settings and are useful for migraine treatment.  In our experience a combination of intravenous fluids, intramuscular ketorolac and promethazine (phenergan) 25 mg intramuscular is a migraine killer.  Again, promethazine should not be used intravenously due to the risk of severe local tissue injury at the injection site. Other commonly utilized antiemetics include3:

  1. Chlorpromazine 0.25 mg/kg up to 25 mg IV/IM
  2. Prochlorperazine 10 mg IV/IM or 25 mg PR

These medications prolong the QT interval and should be avoided in patients with QT prolonging conditions or in combination with other medications that prolong the QT interval.  Moreover, patients may experience drowsiness and will typically need another person to drive them home. Finally, dystonic reactions can occur and the physician should be ready to treat this with diphenhydramine.

Triptans are typically used by patients at home when the first signs or symptoms of a migraine appear.  Once a migraine has fully developed these medications are still effective but may cause a significant exacerbation of the pain for the first several minutes after administration.  Nevertheless, if other treatments fail, a triptan may be used acutely.  Migraine associated gastric stasis limits the utility of orally administered medications so these may be kept in their subcutaneous or intra-nasally administered formulations in the clinic setting. Triptans should be avoided in patients with cardiovascular or cerebrovascular disease and in those with uncontrolled hypertension or who are pregnant3.

Dihydroergotamine is used in the emergency department for migraines.  It is effective for status migrainosis (migraine lasting longer than 72 hours) and in medication overuse headache.  It universally causes nausea so patients must be pretreated with an antiemetic3. These medications are known teratogens and must not be given to pregnant patients.  Similar to triptans, they are also contraindicated in patients with vascular disease and uncontrolled hypertension.

Sphenopalatine nerve block is a safe, minimally invasive procedure with low risk of complications. Evidence of efficacy is limited to several small studies.  Essentially, the physician soaks a cotton tipped applicator in local anesthetic (e.g. 1-4% lidocaine) and then places this on the posterior nasopharynx above the middle turbinate.

The applicator is left in place for 5-10 minutes and provides 50% pain reduction in 55% of patients in one small study5.  A video demonstrating this technique is linked in the reference.

Pitfalls in Acute Migraine Treatment

Treatment of migraines is an art and can be successfully accomplished in a variety of ways. However, there are a few medications which should be avoided.

Corticosteroids have been shown to be effective at reducing migraine headache recurrence in emergency department patients.  The effect is limited to one week and the number needed to treat was nine.  However, the rate of return to the emergency department beyond one week is unchanged. This raises concerns about the possibility of patients who encounter multiple healthcare providers unfamiliar with their history and are administered recurrent doses of corticosteroids with the consequent risks of harm3.

Opioid medications should also be avoided in migraine patients3. They are less effective than alternative migraine treatments and are more likely to interfere with other medications.  Additionally they are associated with an increased rate of migraine recurrence and a higher prevalence of medication overuse headache.  However, they may be considered in pregnant patients with refractory migraine.

 

Migraine Prophylaxis

Recurrent migraines can be debilitating for patients and lead to significant time away from work or school. For patients with more than 2-3 migraine episodes per month we offer migraine prophylaxis. Foundationally, we encourage patients with recurrent headache to keep a headache diary. This can help identify triggers and educate the patient on unhealthy lifestyle choices which lead to migraine headaches.  Common triggers include lack of sleep and exercise, certain foods or beverages and stress.  Avoiding or coping with triggers can help reduce the number of headaches migraineurs experience each month.

There are a number of options available for pharmacologic prophylaxis of migraine headache.  This allows physicians to tailor treatment individually so that co-morbid conditions can be targeted as well.  The table below outlines medications with the highest quality evidence demonstrating efficacy in migraine prophylaxis.

 

Migraine Treatments with High Quality Evidence6

Beta Blockers Notes Adverse Effects
Propranolol 40 mg bid Can take several weeks to work; trial should last 3 months with titration before deemed treatment failure Avoid in pts > 60 yo and smokers (possible increased risk of CVA)
Metoprolol 50 mg bid
Atenolol 25 mg daily
TCAs Beneficial in co-morbid depression Sedation, dry mouth, urinary retention, confusion, arrhythmia
Amitriptyline 10-50 mg po qhs
Anticonvulsants
Valproate 500-1500 mg per day CATEGORY X
Topiramate titrate to 100 mg daily Doses < 100 mg ineffective; 200 mg causes AE in ⅓ of patients Confusion, memory, concentration, etc…

 

Additionally, there are a number of so-called nutraceuticals which have demonstrated efficacy for migraine prophylaxis in small randomized controlled trials.  Those with the current highest quality evidence and best safety profile are listed below6.

  1. Magnesium oxide 400 mg daily is associated with decreased frequency of migraines in some studies.
  2. Riboflavin 400 mg daily is effective for the reduction of migraine occurrence when used consistently for three months consecutively.
  3. Co-enzyme Q10 100 mg three times daily is also useful.

 

Finally, alternative treatments have shown efficacy in migraine prophylaxis as well.  One study comparing accupuncture to placement on a treatment waiting list demonstrated equal reductions in migraine frequency with the use of either sham or traditional methods of needle placement7. Another study evaluated transcutaneous supraorbital nerve stimulation in comparison with a sham treatment and showed reduction in the frequency of migraines8.  It must be noted, however, that this was a small trial and the sham treatment did not result in the notable parasthesia associated with actual nerve stimulation so that it could not be truly blinded.

In conclusion, migraines are a common diagnosis seen in the primary care clinic.  Successful diagnosis requires a systematic approach to headaches.  A basic toolbox for migraine treatment is outlined in this article.  Continuous practice will help the practitioner develop and apply this toolbox to a variety of patients with satisfying results.

 

  1. Bajwa ZH, Smith JH. Preventive treatment of migraines in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed May 8, 2017).
  2. Bainer L, Matheson E. Approach to Acute Headache in Adults. Am Fam Physician. 2013 May 15;87(10):682-687.
  3. Gelfand AA, Goadsby PJ. A Neurologist’s Guide to Acute Migraine Therapy in the Emergency Room. Neurohospitalist. 2012 Apr; 2(2): 51–59.
  4. Zidverc-Trajković J, Pavlović AM, Jovanović Z, Šternić N, Kostić VS. Efficacy of intravenous magnesium sulfate in severe migraine attacks. The Journal of Headache and Pain. 2001;2(2):79-82. doi:10.1007/pl00012190.
  5. Shih J, Gaafary C. Tricks of the Trade: Sphenopalatine nerve block in the treatment of primary headache. Academic Life in Emergency Medicine. Access May 9, 2017.
  6. Bajwa ZH, Smith JH. Preventive treatment of migraines in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed May 8, 2017).
  7. Linde K, Streng A, Jürgens S, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, Pfaffenrath V, Hammes MG, Weidenhammer W, Willich SN, Melchart D. Acupuncture for Patients With MigraineA Randomized Controlled Trial. 2005;293(17):2118-2125. doi:10.1001/jama.293.17.2118
  8. Meng, F.-g. et al. “Migraine Prevention With A Supraorbital Transcutaneous Stimulator: A Randomized Controlled Trial”. Neurology 81.12 (2013): 1102-1103. Web.
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