Migraine Headache Guidelines

Updated: May 28, 2019
  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Helmi L Lutsep, MD  more...
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Guidelines

US Headache Consortium

Pharmacologic treatment for episodic migraine prevention in adults

According to guidelines released by the American Academy of Neurology and the American Headache Society, [147] the following medications are established as effective and should be offered for migraine prevention (level A recommendation):

  • Antiepileptic drugs (AEDs): divalproex sodium, sodium valproate, topiramate

  • β-Blockers: metoprolol, propranolol, timolol

  • Triptans: frovatriptan for short-term MAMs prevention

The following medications are probably effective and should be considered for migraine prevention (level B recommendation):

  • Antidepressants: amitriptyline, venlafaxine

  • β-Blockers: atenolol, nadolol

  • Triptans: naratriptan, zolmitriptan for short-term MAMs prevention

The following medications are possibly effective and may be considered for migraine prevention (level C recommendation):

  • ACE inhibitors: lisinopril

  • Angiotensin receptor blockers: candesartan

  • α-Agonists: clonidine, guanfacine

  • AEDs: carbamazepine

  • β-Blockers: nebivolol, pindolol

NSAIDs and other complementary treatments for episodic migraine prevention in adults

The American Academy of Neurology and the American Headache Society also released guidelines regarding the use of NSAIDs and complementary treatments in preventing episodic migraine. [148]

The following therapy is established as effective and should be offered for migraine prevention (level A recommendation):

  • Petasites (butterbur)

The following therapies are probably effective and should be considered for migraine prevention (level B recommendation):

  • NSAIDS: fenoprofen, ibuprofen, ketoprofen, naproxen, naproxen sodium

  • Herbal therapies, vitamins, and minerals: riboflavin, magnesium, MIG-99 (feverfew)

  • Histamines: histamine SC

The following therapies are possibly effective and may be considered for migraine prevention (level C recommendation):

  • NSAIDs: flurbiprofen, mefenamic acid

  • Herbal therapies, vitamins, and minerals: Co-Q10, estrogen

  • Antihistamines: cyproheptadine

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American Headache Society

Emergency department treatment

In 2016, the American Headache Society (AHS) released guidelines for the management of adults with acute migraine in the emergency department. They recommend intravenous metoclopramide, intravenous prochlorperazine, and subcutaneous sumatriptan to treat these patients (level B recommendation). Dexamethasone should be offered to these patients to prevent recurrence of headache (level B). Opioids (injectable morphine and hydromorphone) should be avoided. [149, 150]

Preventive and acute treatment

An updated position statement from AHS in 2019 offers guidance on preventive and acute treatment of migraine. [151, 152] Recommendations include:

Preventive migraine treatment

Consider preventive treatment for migraine patients in any of the following situations:

  • Migraine attacks are frequent (≥4 migraine headache days per month) and/or the attacks interfere with patients’ daily routines even with acute treatment
  • There is contradiction to, failure, or overuse of acute treatments
  • Acute treatments lead to adverse events

Oral treatments should be offered for migraine prevention. These include antiepileptic drugs, beta-blockers, and frovatriptan. Do not prescribe valproate sodium and topiramate to women who are not using birth control and who may become pregnant.

Start oral treatments at a low dose and titrate slowly.

Give oral treatments for at least 8 weeks to optimize therapeutic response.

Acute migraine treatment

Use evidence-based treatment at the first sign of a migraine attack.

Use NSAIDs (including aspirin), nonopioid analgesics, acetaminophen, or caffeinated analgesic combinations for mild‐to‐moderate attacks and migraine‐specific agents (triptans, dihydroergotamine) for moderate or severe attacks and mild‐to‐moderate attacks that respond poorly to NSAIDs or caffeinated combinations. 

Use a nonoral option for select patients, including those with nausea or vomiting or those who have trouble swallowing.

Options for outpatient rescue include SC sumatriptan, DHE injection or intranasal spray, or corticosteroids. Inpatient options may include parenteral formulations of triptans, DHE, antiemetics, NSAIDs, anticonvulsants (eg, valproate sodium and topiramate, except in women of childbearing age who are not using reliable birth control), corticosteroids, and magnesium sulfate.

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