Medical Inspection – Health Blog

Nonpharmacologic treatment modalities, such as relaxation training, thermal biofeedback combined with relaxation training, electromyographic biofeedback, and cognitive-behavioral therapy, should be considered as treatment options. The U.S. Headache Consortium recommended the aforementioned treatment modalities as Grade A. Grade B recommendations, such as behavioral therapy, were also suggested in conjunction with preventive therapy. Evidence-based treatment for migraine with hypnosis, acupuncture, transcutaneous electrical nerve stimulation, chiropractic or osteopathic cervical manipulation, occlusal adjustment, and hyperbaric oxygen are not available and therefore are not recommended until further evidence is available. Nonpharmacologic treatment should always begin with lifestyle changes and avoidance of potential triggers.

Patients should be advised to exercise regularly, avoid irregular sleeping habits, and quit smoking. Any unnecessary medications that could contribute to the headache should be discontinued. Once an attack occurs, resting in a dark, quiet environment will help in relieving the migraine-associated symptoms.
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PHARMACOLOGIC THERAPY

Prophylactic Treatment

The goals of preventive treatment are to decrease the severity, frequency, and duration of migraine attacks; improve outcomes of acute treatment medications; and improve function and reduce disability. Patients should also be started on preventive therapy if they have recurring migraines that interfere with their daily routine despite acute treatment. Furthermore, preventive therapy should be considered in patients who experience frequent headaches, who have contraindications or adverse events and/or who fail to gain relief from acute treatment medications, or who overuse acute therapy. Based on the U.S. Headache Consortium consensus panel recommendations, preventive therapy should also be used in patients with uncommon headache conditions, such as hemiplegic migraine, basilar migraine, migraine with prolonged aura, or migrainous infarction, to prevent neurologic damage.

If the decision is made to use preventive medications, therapy should be initiated with medications with the highest level of evidence-based ef-ficacy. Therapy should be initiated at the lowest effective dose and the patient should remain on the medication for an adequate length of time (2-3 months to achieve maximum clinical benefit) to assess efficacy. The patient’s response to therapy should be monitored with a headache diary, and therapy should be reevaluated periodically. If the migraines are well controlled for three to six months, therapy should be tapered and discontin-ued. Many migraine patients have comorbid disease states that must be considered when selecting a preventive agent. Conditions that are more common in migraine patients include stroke, myocardial infarction, Ray-naud’s phenomenon, epilepsy, and affective and anxiety disorders. Preferably, the preventive agent in question should treat the migraine and the comorbid illness without exacerbating the migraine. Preventive agents and their level of efficacy according to the U.S. Headache Consortium are listed in Table 2.

Table 2 Preventive Agents and Their Level of Efficacy

Acute Treatment

The goals of acute treatment are to decrease the severity or completely abolish the migraine and return the patient back to functionality as quickly as possible with the fewest adverse effects. Based on the patient preference surveys mentioned earlier, the ideal pharmacological agent should treat the attack rapidly and consistently, with minimal recurrence, and should minimize associated symptoms, such as nausea and vomiting. Furthermore, the agent should be easy to use and appropriate for self-care to decrease the use of resources, to be cost-effective, and to have a low adverse-effect profile. Currently, because of advances in research and enhanced understanding of the pathophysiology of migraine headache, we have a large array of pharmacologic agents from which to choose (Table 3). Nonetheless, agents that are available now still do not fulfill all of the ideal characteristics desired by patients, and so the search for the ideal agent is ongoing.

Table 3 Acute Treatment of Migraine Attacks

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