Population: Adults with migraine headache.
Organization
American Headache Society 2019
Recommendations
Evaluation
–Diagnose migraine using ICHD-3 criteria (Table 28–1).
Management
–Treat migraines at the first sign of pain.
–For mild-to-moderate attacks, use nonsteroidal anti-inflammatory drugs (NSAIDs), nonopioid analgesics, acetaminophen, or combinations such as aspirin + acetaminophen + caffeine.
–For moderate or severe attacks or milder attacks that fail initial therapy, use triptans or ergotamine derivatives. Antiemetics and IV magnesium (in migraine with aura) are also likely effective.
–Offer prophylaxis if frequent attacks that interfere with regular routines and treatments fail or are overused (ie, used 10+ d/mo).
• Frequency: offer prophylaxis if 6+ headache days per month, 4+ days per month with some disability, or 3+ days per month with severe disability. May consider for interested patients with lower headache frequency.
–Offer a prevention agent with established efficacy, starting at a low dose and titrate gradually to response or intolerance. Give a trial of at least 8 wk at target dose and set expectations that a 50% reduction in headache days or a decrease in severity are the goals of therapy. Consider combination therapy if incomplete response. These agents include:
• Antiepileptics: divalproex sodium, valproate sodium, topiramate.
• Beta-blockers: metoprolol, propranolol, timolol.
TABLE 28–1 INTERNATIONAL CLASSIFICATION OF HEADACHE DISORDERS CRITERIA FOR MIGRAINE |
|---|
Episodic |
Five attacks with the following criteria, not explained by another condition: |
– Duration 4–72 h untreated – ≥2 of the following characteristics: unilateral location, pulsating quality, moderate or severe intensity, aggravated by (or causing avoidance of) routine physical activity – Nausea, vomiting, or photophobia and phonophobia |
Chronic |
≥15 d/mo for >3 mo of migraine or tension-type HA H/o at least 5 episodic migraine attacks ≥8 d/mo with ≥2 of the following characteristics: unilateral location, pulsating quality, moderate or severe intensity, aggravated by (or causing avoidance of) routine physical activity plus duration 4–72 h if migraine with aura or nausea, vomiting or photo/phonophobia if migraine without aura, that patient believes to be a migraine and gets relief from triptan or ergot derivative |
• Triptans: frovatriptan (only for short-term prevention of menstrual migraine).
• Onabotulinumtoxin A.
–Consider agents with probable effectiveness:
• Antidepressants: nortriptyline, venlafaxine.
• Beta-blockers: atenolol, nadolol.
–If the above are ineffective or if the patient prefers, consider an agent with a single small study of effectiveness: lisinopril, clonidine, guanfacine, carbamazepine, nebivolol, pindolol, cyproheptadine, candesartan.
–Data are insufficient to recommend novel injectable biologic agents for prophylaxis, as they lack long-term safety data and carry uncertain cost-effectiveness.
Source
–Headache. 2019;59:1-18.
Population: Children and adolescents with migraine headache.
Organization
AAN 2019
Recommendations
Evaluation
–Diagnostic criteria for pediatric migraine:
• At least 5 headaches over the past year that lasted 2–72 h when untreated.
• Associated with nausea, vomiting, photophobia, or phonophobia.
• 2 of 4 additional features:
Pulsatile quality.
Unilateral.
Worsening with activity or limiting activity.
Moderate-to-severe in intensity.
Management
–Treat migraine early (within <1 h of headache onset).
–Offer nonprescription oral analgesics like acetaminophen, ibuprofen, and naproxen.
–Consider triptans, though they are less commonly prescribed in children than in adults.
• Agents FDA-approved for children: almotriptan (age ≥12 y), rizatriptan (age 6–17 y), sumatriptan/naproxen (aged ≥12 y), and zolmitriptan NS (age ≥12 y).
• If incomplete response to triptan, add NSAID (ibuprofen or naproxen).
• Do not prescribe triptans to those with history of ischemic vascular disease or accessory conduction pathway disorders, as the medication can exacerbate these disorders.
• Timing: taking triptan during a typical aura is safe, but it may be more effective if taken at onset of head pain.
–If HA is successfully treated with acute medication but recurs within 24 h, repeat the initial treatment.
–If prominent nausea or vomiting, offer antiemetics.
–Ergots have not been studied in children.
–Consider referral to headache specialist if hemiplegic migraine, migraine with brainstem aura who do not respond to initial treatments.
Source
–Neurology. 2019;93:487-499.