Headache can be a simple nuisance or annoyance, or it may be disabling or herald a sinister problem. This article focuses on management of migraines, the most common headache type for which patients consult physicians. Primary care physicians can effectively manage the vast majority of migraine patients once the diagnosis has been established. This Special Report emphasizes individualized treatment matching patients’ migraine characteristics withappropriate treatment. Physicians can play a key role in enabling patients to achieve quick and effective migraine relief, allowing them to return to their pre-migraine levels of activity and productivity.

While there are literally hundreds of different kinds of headaches, migraine is the most common disabling type.¹ Migraines can occur in children, teenagers and adults, with the highest prevalence between the ages of 20 and 55 years; migraines are estimated to occur in roughly 18% of women and 7% of men.² Migraine is a common cause of school and workplace absenteeism as well as presenteeism (decreased function and productivity at work). Migraine frequently interferes with family life, social and recreational pursuits.³ While episodic tension-type headache⁴ is the most common variety of headache in the general population, migraine is the most common headache type leading to physician visits.²

Ask your patients about their headaches

The physician’s goal is to manage the patient’s most disabling headaches and educate the patient about how to identify and stratify treatment for their different headache types. Start by asking them to tell you about their bad headaches:

Migraines are often unilateral but can be bilateral; the pain may be frontal, temporal, retro-orbital, occipital-nuchal or any combination thereof. Most migraineurs (people with migraines) report a throbbing or pulsing quality to their headache, but some describe a pressure or simply cannot describe the quality of the pain. Untreated, these headaches typically are of moderate-to-severe intensity or are incapacitating. Generally, during an attack individuals prefer to sit still or lie on the couch or bed; exertion or exercise usually worsens the symptoms. Many migraineurs are nauseated and some vomit during attacks; neither is necessary for the diagnosis of migraine.4 Similarly, many migraineurs experience sensitivity to light, sounds, smells or motion.⁴

Ask about the medications they take

You need to know: what medication(s) your patients take for their migraines; when they take them in relation to headache onset (i.e. when pain is mild or severe); what dose they use; and what is the average and maximum number of tablets consumed during a 24-hour period for each medication during a migraine attack.

Are your patients getting enough rest and eating regularly?

Migraineurs inherit the susceptibility to headaches, but numerous endogenous and exogenous factors can influence when they experience attacks. It is critical that migraine sufferers limit all modifiable triggers. Specifically, it is crucial to strongly encourage all migraineurs to try to get up and go to bed at the same time every day to ensure that they maintain a consistent sleep schedule, receive adequate sleep and wake up rested. They should eat a minimum of three meals per day at regular times (no skipped or missed meals), exercise regularly (ideally in the morning), drink four to six non-caffeinated beverages daily, and minimize stress or learn to better cope with stress (relaxation strategies, yoga, biofeedback or other bio-behavioural techniques via a psychologist, psychotherapist or self-learning). While menstrual cycles and weather changes can precipitate migraines in some, these are non-modifiable factors — migraineurs need to focus on adherence to lifestyle strategies to mitigate their migraine attacks.

Do patients know when a migraine is beginning?

For some migraineurs the first sign is throbbing, for others it’s sensitivity to light/sounds, and for others irritability. Patients usually need to treat while the headache is still in the mild- to moderate-intensity stage. Left untreated for hours, migraines can escalate to a critical point where they are no longer responsive to oral therapies.

Effective early treatment

There are numerous options for acute migraine relief, and patients vary in their responses to different medications. While less medication is certainly preferable, aggressive therapy at the onset of a migraine attack often reduces the overall quantity of medication(s) utilized (when compared to a migraine treated ineffectively in the early stages that then persists for 24–72 or more hours). Choices include over-the-counter simple analgesics (acetaminophen, ibuprofen, acetylsalicylic acid), over-the-counter combination analgesics (acetaminophen with caffeine), prescription nonsteroidal anti-inflammatory drugs (NSAIDs), narcotics, combination narcotic analgesics (codeine with or without caffeine, butalbital or muscle relaxants), ergotamines and triptans. Important, but often forgotten, are over-the-counter antiemetics (oral or rectal suppository) and prescription antiemetics (e.g. metoclopramide).⁶ For severe headaches, combinations of certain headache medications can provide additional relief.³ For example, patients can be educated to utilize any combination of acetaminophen ± ibuprofen/acetylsalicylic acid ± a triptan ± an antiemetic.

Triptans are migraine-specific

For migraines of moderate or severe intensity, triptans are the most effective single medication, especially when taken early.⁶ It is a misconception that they are “strong” agents.⁴ They are migraine-specific “designer” drugs that do not treat the pain associated with other non-headache conditions.⁴ Seven triptans are now available in Canada. Patients often respond differently to different triptans; correspondingly, if patients are not tolerating one agent well and/or are not obtaining consistent, meaningful and lasting relief, they should be tried on alternative triptans.⁷ When nausea or vomiting is prominent, non-oral routes of triptan administration or addition of anti-emetic treatments can be considered.

Triptans are a very safe and well-tolerated class of medications.⁸ A small minority of individuals experience non-cardiac chest or throat tightness and/or fatigue/fogginess with triptans. The likelihood of these unpleasant symptoms is reduced with several of the newer triptans.⁸ All triptans are contraindicated in patients with a history of coronary artery or cerebrovascular disease, significant peripheral vascular disease, uncontrolled hypertension, hemiplegic or basilar migraine, and during pregnancy. Fortunately, the overwhelming majority of migraineurs do not have contraindications to triptan use. The likelihood of serotonin syndrome, a severe adverse drug reaction that has been reported to occur when triptans and selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) are combined, is extremely rare,⁹ and headache experts generally do not avoid using triptans in patients taking an SSRI or SNRI.

Avoiding medication overuse and dose-related side effects

When headaches occur on more than 10 days per month, regular early treatment can lead to medication overuse (rebound) headache. Such patients need to try to limit their acute migraine medications to less than 10 days per month. When this is not possible, they need to rotate their therapies (i.e. triptans < 10 days per month, prescription NSAIDs < 10 days per month, other analgesics < 10 days per month) to avoid both medication overuse and dose-related side effects. As well, when patients experience headaches > 10 days per month, you should strongly emphasize preventative lifestyle strategies and consider prophylactic therapy.

Preventive therapy

When migraines occur too frequently, last too long, cause too much disability, and/or acute medications are costing the patient too much, prophylactic therapy should be considered. The goal of prophylactic therapy is NOT to cure headaches but to try to decrease their frequency, severity, duration and/or disability. There are numerous medications to choose from. First-line therapies are usually tricyclic antidepressants (e.g. amitriptyline 10 mg po qhs and increasing by 10 mg every 1–2 weeks as necessary and tolerated to >/= 50 mg po qhs), beta-blockers (e.g. nadolol 20 mg po BID and increasing q 7 days to 40 mg po BID or higher as necessary and tolerated) or anticonvulsants (e.g. topiramate 12.5 mg po qhs and increasing as necessary and tolerated by 12.5 mg every week to about 100 mg po qhs). Alternative options include calcium channel blockers (e.g. verapamil 80 mg po TID, flunarizine 5–10 mg po qhs), other anticonvulsants (e.g. gabapentin, divalproex), miscellaneous medications (pizotifen, methysergide), interventional therapies from a neurologist/headache expert (i.e. botulinum toxin type A; note that use for headache prophylaxis has not been approved by Health Canada), or naturopathic options (e.g. feverfew, Petasites hybrid [butterbur], riboflavin and magnesium). Advise patients to start at the lowest dose possible and titrate the dose upwards as necessary and tolerated. Inform them that:

• the medications require several weeks to start working
• improvement not cure is the goal
• a 12-week minimum trial is necessary.

Prophylactic medications are to be taken as prescribed, not on an as-needed basis. As well, inform patients that no drug is consistently effective in preventing migraine: in clinical practice, each has been found to work in about 50% of patients. It is very important to advise patients about the conventional use of a given prescribed prophylactic option (at higher doses), and to explain that this medication is now frequently utilized at lower doses to control migraines. A significant number of patients never take their prescribed prophylactic therapy after learning from a pharmacist or Internet source that the medication is actually an antidepressant, anticonvulsant or blood pressure medication.