Evaluation and Treatment of the Adult Patient With Migraine
Mild to moderate migraine can be treated effectively with an oral combination of aspirin, acetaminophen, and caffeine (Excedrin or generic substitutes) or aspirin plus metoclopramide (LOE: A). Patients who cannot take aspirin may respond to 1000 mg acetaminophen alone (LOE: B).
Triptans (5-hydroxytryptamine1B/1D receptor agonists) are the drugs of choice for the acute treatment of moderate to severe migraine (except hemiplegic or basilar migraine) (LOE: A). Contraindications include coronary artery disease, uncontrolled hypertension, pregnancy, and recent monoamine oxidase inhibitor or ergot alkaloid use. Little evidence exists to recommend one triptan over another. A few studies suggest that the newer oral triptans may be slightly more efficacious than oral sumatriptan, although the differences do not appear overwhelming.14-16
There have been no recent studies on isometheptene-containing compounds such as Midrin. Three randomized placebo-controlled trials in the mid-1970s found a modest but statistically significant effect on migraine pain.17-19 However, the lack of standardized inclusion criteria and outcome measures makes it difficult to draw firm, valid conclusions about the efficacy of isometheptene.20 These drugs should be considered second line in the acute treatment of migraine (LOE: B).
A number of randomized controlled studies have demonstrated the efficacy of acetaminophen–codeine combinations in the acute treatment of migraine.21-23 Some of these trials have used combinations that included other medications in addition to acetaminophen and codeine; no study has been done on the dose most readily available in the United States (ie, 300 mg acetaminophen plus 30 mg codeine). Concerns about abuse, tolerance, and rebound headache appropriately limit their use. In addition, there is no evidence that they are more effective than other abortive treatments; one study showed no difference between the acute migraine relief provided by 1000 mg plain aspirin versus 400 mg acetaminophen and 25 mg codeine.21 While acetaminophen plus codeine combinations probably are effective in migraine, they are second-line drugs (LOE: B).
No randomized, placebo-controlled trials have evaluated the efficacy of butalbital-containing agents for migraine. Because of concerns relating to dependence, withdrawal, and rebound headache, the USHC recommends that use of these agents “should be limited and carefully monitored” (LOE: D).12
In the emergency department setting, prochlorperazine (10 mg given intravenously [IV]) is a safe and effective treatment for migraine (LOE: A).24 Dihydroergotamine (DHE) given IV or intramuscularly (IM) in combination with antiemetics is at least as good as meperidine (IV or IM) in relieving the pain of migraine (LOE: A).25,26 Despite the widespread use of parenteral meperidine in this setting, there are no placebo-controlled studies documenting its effectiveness in the treatment of migraine headache.
TABLE 3
SELF-ADMINISTERED ACUTE TREATMENT OPTIONS IN MIGRAINE
| Strength of Recommendation | Treatment (Route of Administration) | Comments |
|---|---|---|
| A | Acetaminophen +aspirin + caffeine (PO) | NNT* 3.9 (3.2 to 4.9)51 |
| A | Aspirin (PO) | NNT range from 3.5 to 5.552 |
| A | Aspirin + metoclopramide (PO) | NNT 3.2 (2.6 to 4.0)53 |
| A | Butorphanol (IN) | Abuse/dependence and rebound headache potential |
| A | DHE (IN) | NNT 2.5 (1.9 to 3.7)54 |
| A | NSAIDs (PO) | NNT 7.5 (4.5 to 22) (for ibuprofen)55 |
| A | Triptans (PO) | NNT range from 2.7 to 5.456 |
| A | Sumatriptan (IN) | NNT 3.4 (2.9 to 4.1)56 |
| A | Sumatriptan (SC) | NNT 2.0 (1.8 to 2.2)56 |
| B | Acetaminophen (PO) | NNT 5.2 (3.3 to 13)57 |
| B | Acetaminophen + codeine (PO) | Abuse/dependence and rebound headache potential |
| B | Isometheptene compounds (PO) | Limited clinical trial data. |
| D | Butalbital compounds (PO) | No clinical trials; risk of rebound headache |
| D | Ergotamine (PO) | Conflicting evidence; increased risk of adverse effects |
| * Numbers needed to treat (NNT; 95% confidence interval) in this column are for headache response (reduction in headache severity from “severe” or “moderate” to “mild” or “none”) at 2 hours; included when available data permit. | ||
| IN denotes intranasal; PO, by mouth; SC, subcutaneous. | ||
Prophylactic medications
The USHC recommends that preventive treatment be considered for patients with migraine who desire a reduction in the frequency or severity of their headaches for any reason, including but not limited to frequent headaches that significantly interfere with daily activities despite acute treatment, unpleasant side effects associated with abortive medications, or the cost of abortive medications (LOE: D).27Table 4 lists medications available in the United States that are used in the prophylaxis of migraine.
Beta blockers, particularly propranolol, are commonly prescribed and are very effective in reducing the frequency of migraine (LOE: A).27-30 Most authorities consider them the migraine prophylactic of choice in patients with no contraindications (eg, asthma, congestive heart failure, or heart block).
Amitriptyline is the only antidepressant to demonstrate consistent efficacy in migraine prophylaxis.27,31,32 This medication may be especially useful in patients who suffer from both migraine and tension headaches.33 Divalproex sodium is another drug clearly shown effective against migraine prophylactically.27,30,34 The risk of significant hematologic and hepatic side effects requires laboratory monitoring and may limit its use in many patients.
Calcium channel blockers (CCBs), particularly verapamil, are widely used by both primary care physicians and neurologists for the prevention of migraine,35 and yet only 3 controlled trials of verapamil are reported in the English language literature. Two methodologically weak studies showed a small but significant effect from verapamil36,37; the third demonstrated no advantage over placebo.38 The only CCB consistently shown effective for migraine prophylaxis is flunarizine.27 Unfortunately, it is not available in the United States.
