Treatment

All patients

• Limit stimuli (i.e., light, loud noises) and activity.

• Start abortive treatment as soon as possible. [19]

• Treat nausea and vomiting, if present.

  • IV fluids

  • Parenteral antiemetics: e.g., metoclopramide, prochlorperazine

• First-line treatment consists of NSAIDs, acetaminophen, acetylsalicylic acid, or combinations including caffeine.

  • If tolerating PO, consider one of the following:

    • Ibuprofen

    • Aspirin

    • Acetaminophen

    • Acetaminophen/aspirin/caffeine

  • If nausea/vomiting are present, consider one of the following:

    • Ketorolac

    • Diclofenac

• Second-line: Treat as “Moderate to severe headache.”

• Children: ibuprofen and family counseling

Trial a parenteral antidopaminergic agent OR start a migraine-specific agent.

• Parenteral antidopaminergics

  • Metoclopramide

  • Prochlorperazine PLUS diphenhydramine [15][20]

• Migraine-specific agents: triptans (e.g., sumatriptan) OR ergotamine; do not combine these agents! [21]

  • First-line: oral or parenteral triptans

    • If tolerating PO, consider one of the following:

      • Sumatriptan-naproxen

      • Zolmitriptan

    • If nausea/vomiting are present or there is a higher analgesic requirement, consider one of the following:

      • Sumatriptan

      • Zolmitriptan

  • Second-line: consider a parenteral ergotamine (e.g., dihydroergotamine)

• Short-term recurrence prevention: Consider IV dexamethasone. [22]

• Refractory headache: See “Status migrainosus.”

Parenteral antidopaminergics (i.e., IV metoclopramide or IV prochlorperazine) are effective first-line agents for migraine regardless of GI symptoms or ability to tolerate oral medication.

• Lifestyle modifications

  • Exercise in moderation

  • Maintain a healthy diet

  • Identify and try to avoid potential triggers

  • Follow a regular sleeping schedule

• Other: There is some evidence that the following nonpharmacological interventions have some benefits for patients with migraine

  • Acupuncture [26]

  • Noninvasive neuromodulation

  • Behavioral therapy

  • Relaxation techniques

  • Biofeedback

• Indications [28][29]

  • ≥ 2 attacks/month that produce disability that lasts ≥ 3 days

  • Severe disability regardless of frequency (e.g., hemiplegic migraine)

  • ≥ 2 attacks/week regardless of severity

  • Failure/contraindications/major side effects from acute medications

• General prophylaxis

  • First-line [27]

    • Anticonvulsants (e.g., topiramate, valproate)

    • Beta blockers (e.g., propranolol , metoprolol, timolol)

  • Second-line [27]

    • Tricyclic antidepressant: amitriptyline

    • NSAIDs: fenoprofen

  • Other: calcium channel blockers (e.g., flunarizine)

Status migrainosus

• Description: Debilitating migraine attack in a patient with a known migraine diagnosis (with or without aura)

  • Exceptional in duration (≥ 72 hours) and severity

  • Often related to medication overuse

• Treatment: stepwise therapy with reassessment between drug administration

  • IV fluids

  • Antiemetic (e.g., metoclopramide)

  • NSAID (e.g., ketorolac)

  • Dihydroergotamine

  • Dexamethasone

  • Valproate [32]