Case Continued
Our patient has a normal neurologic examination and classic migraine headache history and stable frequency. The physician tells her she meets criteria for episodic migraine without aura. The patient asks if she needs a “brain scan” to see if something more serious may be causing her symptoms.
What workup is recommended for patients with migraine?
If patient symptoms fit the criteria for migraine and there is a normal neurologic examination, the differential is often limited. When there are neurologic abnormalities on examination (eg, papilledema), or if the patient has concerning signs or symptoms (see below), then neuroimaging should be obtained to rule out secondary causes of headache.
In 2014, the American Academy of Neurology (AAN) published practice parameters on the evaluation of adults with recurrent headache based on guidelines published by the US Headache Consortium [40]. As per AAN guidelines, routine laboratory studies, lumbar puncture, and electroencephalogram are not recommended in the evaluation of non-acute migraines. Neuroimaging is not warranted in patients with migraine and a normal neurologic examination (grade B recommendation). Imaging may need to be considered in patients with non-acute headache and an unexplained abnormal finding on the neurologic examination (grade B recommendation).
When patients exhibit particular warning signs, or headache “red flags,” it is recommended that neuroimaging be considered. Red flags include patients with recurrent headaches and systemic symptoms (fever, weight loss), neurologic symptoms or abnormal signs (confusion, impaired alertness or consciousness), sudden onset, abrupt, or split second in nature, patients age > 50 with new onset or progressive headache, previous headache history with new or different headache (change in frequency, severity, or clinical features) and if there are secondary risk factors (HIV, cancer) [41].
Case Continued
Our patient has no red flags and can be reassured that given her normal physical examination and history suggestive of a migraine, a secondary cause of her headache is unlikely. The physician describes the treatments available, including implementing lifestyles changes and preventive and abortive medications. The patient expresses apprehension about being on prescription medications. She is concerned about side effects as well as the need to take daily medication over a long period of time. She reports that these were the main reasons she did not take the rizatriptan and propranolol that was prescribed by her previous doctor.
How is migraine treated?
Migraine is managed with a combination of lifestyle changes and pharmacologic therapy. Pharmacologic management targets treating an attack when it occurs (abortive medication), as well as reducing the frequency and severity of future attacks (preventive medication).
Lifestyle Changes
Patients should be advised that making healthy lifestyle choices, eg, regular sleep, balanced meals, proper hydration, and regular exercise, can mitigate migraine [42–44]. Other lifestyle changes that can be helpful include weight loss in the obese population, as weight loss appears to result in migraine improvement. People who are obese also are at higher risk for the progression to chronic migraine.
Acute Therapy
There are varieties of abortive therapies [45] (Table 4) that are commonly used in clinical practice. Abortive therapy can be taken as needed and is most effective if used within the first 2 hours of headache. For patients with daily or frequent headache, these medications need to be restricted to 8 to 12 days a month of use and their use should be restricted to when headache is worsening. This usually works well in patients with moderate level pain, and especially in patients with no associated nausea. Selective migraine treatments, like triptans and ergots, are used when nonspecific treatments fail, or when headache is more severe. It is preferable that patients avoid opioids, butalbital, and caffeine-containing medications. In the real world, it is difficult to convince patient to stop these medications; it is more realistic to discuss use limitation with patients, who often run out their weekly limit for triptans.
Triptans are effective medications for acute management of migraine but headache recurrence rate is high, occurring in 15% to 40 % of patients taking oral triptans. It is difficult to predict the response to a triptan [46]. The choice of an abortive agent is often directed partially by patient preference (side effect profile, cost, non-sedating vs. prefers to sleep, long vs short half-life), comorbid conditions (avoid triptans and ergots in uncontrolled hypertension, cardiovascular disease, or peripheral vascular disease or stroke/aneurysm; avoid NSAIDS in patients with cardiovascular disease), and migraine-associated symptoms (nausea and/or vomiting). Consider non-oral formulations via subcutaneous or nasal routes in patients who have nausea or vomiting with their migraine attacks. Some patients may require more than one type of abortive medication. The high recurrence rate is similar across different triptans and so switching from one triptan to another has not been found to be useful. Adding NSAIDS to triptans has been found to be more useful than switching between triptans.Overuse of acute medications has been associated with transformation of headache from episodic to chronic (medication overuse headache or rebound headache). The risk of transformation appears to be greatest with medications containing caffeine, opiates, or barbiturates [47]. Use of acute medications should be limited based on the type of medication. Patients should take triptans for no more than 10 days a month. Combined medications and opioids should be used fewer than 8 days a month, and butalbital-containing medications should be avoided or used fewer than 5 days a month [48]. Use of acute therapy should be monitored with headache calendars. It is unclear if and to what degree NSAIDS and acetaminophen cause overuse headaches.
Medication overuse headache can be difficult to treat as patients have to stop using the medication causing rebound. Further, headaches often resemble migraine and it can be difficult to differentiate them from the patients’ routine headache. Vigilance with medication use in patients with frequent headache is an essential part of migraine management, and patients should receive clear instructions regarding how to use acute medications.