Migraine is a leading cause of years lived with disability worldwide.¹ Once a migraine diagnosis has been made, development of a well-informed, individualized, and flexible management plan is vital to ensure an optimal treatment course for each patient.

Evaluation of patient-specific migraine characteristics

Most migraine diagnoses are classified into one of three types: episodic migraine with aura, episodic migraine without aura, or chronic migraine.² Even within the same type of migraine, however, symptoms and presentation can vary greatly from patient to patient, and can also change over time. Thus, every migraine management plan must consider behavioral, acute and preventive treatments that fit individual needs.³

Primary care providers (PCPs) play a pivotal role for migraine patients, since headache is one of the most common neurologic reasons for consulting a PCP.³ It is important for PCPs to have clarity on specific recommendations and guidelines for diagnostic criteria, as underuse of such resources may contribute to misdiagnoses.³ The third edition of the International Classification of Headache Disorders (ICHD-III), among other resources, provides useful standards for clinicians.⁴

Importance of personalized migraine management plans

Patient preference is important to consider when making treatment decisions since shared decision-making may lead to improved outcomes.⁵ Staying flexible and changing strategies as needed, as well as frequently re-evaluating treatment effectiveness, are critical aspects of improving each patient’s quality of life and migraine management.

Guidelines for migraine diagnosis and management

PRINCIPLES OF MIGRAINE MANAGEMENT

Several guidelines and recommendations for the management of migraine have been developed, incorporating guidance on new acute and preventive medications.

In 2019, the second edition of the European Headache Federation (EHF) guidelines provided ‘Aids to management of headache disorders in primary care’.² In 2021, a ten-step approach to the diagnosis and management of migraine was established by a European panel of experts, which was endorsed by the EHF and the European Academy of Neurology (EAN).⁶

Additionally, the 2021 American Headache Society (AHS) consensus statement provides updated guidance on the use of new acute and preventive treatments for migraine, including the goals of treatment, approved indications for usage, and strategies for developing personalized treatment plans.⁵

NON-PHARMACOLOGICAL OR LIFESTYLE MANAGEMENT

Lifestyle and habitual modifications that may help to alleviate symptoms and frequency of attacks should not be overemphasized, but should be considered early.² Recognizing and avoiding triggers, having a regular day-to-day schedule, getting enough sleep and exercise, and stopping smoking may benefit individual patients.³ Common additional behavioral interventions include relaxation training, biofeedback, and cognitive behavioral therapy, which have shown improved outcomes both alone and with pharmacotherapy.⁷ Newer non-pharmacological treatments are now emerging for migraine, including remote electrical neuromodulation, transcranial magnetic stimulation, external trigeminal nerve stimulation, and non-invasive vagus nerve stimulation.⁵

ACUTE OR SYMPTOMATIC TREATMENT FOR EPISODIC MIGRAINE

The EHF guidelines state that generally, all adults experiencing episodic migraine should have access to acute medication, while children may respond well to bedrest without medical treatment.² For children and adolescents, a more in-depth update to the guidelines for acute treatment was published by the American Academy of Neurology.⁸

According to the AHS consensus statement, the goals of acute treatment in adults include:⁵

- Rapid and consistent relief from pain and associated symptoms without recurrence
- Restored ability to function
- Minimal need for repeat dosing or rescue medications
- Optimal self-care and reduced subsequent use of resources
- Minimal or no adverse events

Triptans, ergotamine derivatives, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and combination medications are considered “effective” for the acute treatment of migraine in adults.⁹ The recent AHS consensus statement includes recommendations for the use of newly introduced acute treatments, including small-molecule calcitonin gene-related peptide (CGRP) receptor agonists, serotonin agonists, and NSAIDs.⁵ Both the AHS consensus statement and EHF guidelines state that caution should be taken to avoid overuse of acute medication (>2 days per week), as this may increase the risk of developing medication-overuse headache.^2,9

PREVENTIVE TREATMENT

According to the AHS consensus statement, the goals of preventive migraine treatment are to:⁵

- Reduce attack frequency, severity, duration, and disability
- Improve responsiveness to and avoid escalation in use of acute treatment
- Improve function and reduce disability
- Reduce reliance on poorly tolerated, ineffective, or unwanted acute treatments
- Reduce overall cost associated with migraine treatment
- Enable patients to manage their own disease to enhance a sense of personal control
- Improved health-related quality of life
- Reduce headache-related distress and psychological symptoms

The EHF recommends offering prophylaxis to all adults and children whose migraine is not well controlled by acute treatment alone.² While referrals to specialists should be provided for children requiring prophylactic medication,² many options—of varied efficacy across individuals—are available for adults. Practice guidelines are available for acute and preventive treatment of migraine in children and adolescents.^8,10

Prophylactic options with evidence of varied efficacy in adults include anticonvulsants, beta-adrenergic blockers, triptans, antidepressants, angiotensin II-receptor blockers, and calcium antagonists.¹¹ The more recent AHS consensus paper includes CGRP pathway monoclonal antibodies (mAbs) as an effective migraine preventive therapy.⁵

The 2022 EHF guidelines also recommend that CGRP pathway mAbs be included as a first-line preventive treatment option for people with migraine.¹² Treatment with CGRP pathway mAbs may be paused after 12–18 months of continuous treatment; however, treatment can be continued as long as required.¹²

CHRONIC MIGRAINE AND MEDICATION OVERUSE

Chronic migraine may develop in a minority of patients living with episodic migraine, and is often complicated by medication overuse and comorbidities such as depression and anxiety.² These cases can be particularly difficult to treat, and are likely to require specialist management.² Lifestyle modifications and educating patients about their condition, management of medication use, comorbidities, preventive treatment, and follow-up are included in the AHS consensus statement and EHF principles of management.^2,5

COMORBIDITIES

Common comorbidities with migraine include fibromyalgia, depression, obesity, epilepsy, and hypertension.³ Migraine management in patients with comorbidities may involve choosing treatments that are known to have efficacy for the comorbid condition, and avoiding drugs that may exacerbate the condition or interact with other medications.⁵ Optimal treatment may require the use of separate classes of medications to treat multiple conditions.⁵ The AHS consensus statement suggests use of neuromodulatory devices for patients who may benefit from preventive treatment but must limit or avoid specific medications due to comorbid conditions.⁵

Treatment response

LOW COMPLIANCE AND ADHERENCE TO TREATMENT

Adherence to oral preventive medications in patients with migraine is suboptimal, with 86% discontinuing a first-line treatment within one year.¹³ Persistence worsens as patients cycle through treatment,¹³ and patients who have discontinued two treatments have a higher burden of migraine.¹⁴ Additionally, patients often avoid seeking help entirely or stop treatment because of the stigma and false preconceptions that surround migraine.¹⁵ The use of injectable preventive medications such as onabotulinumtoxinA or CGRP pathway mAbs may improve adherence due to the reduced dosing frequency compared with orally administered drugs.⁵ The EHF advises keeping a headache diary with a calendar to assess drug efficacy, as well as giving two to three months before discontinuing prophylactic medication that appears ineffective.²

NEED FOR CONTINUED RE‑EVALUATION

To encourage more patients to start and stay on preventive treatment, various aspects of migraine management, including the diagnosis, duration, and use (and possible overuse) of acute medication must be periodically re-evaluated to find areas of improvement.² Re-informing patients about their condition may also be beneficial, so that any disparate information between patient and clinician can be realized.² Patients should be encouraged to continue their headache diary to help identify progress or problems in their treatment regimens.¹⁶

References

1. Stovner LJ, Hagen K, Linde M, Steiner TJ. The global prevalence of headache: an update, with analysis of the influences of methodological factors on prevalence estimates. J Headache Pain 2022;23:34.
2. Steiner TJ, Jensen R, Katsarava Z, et al. Aids to management of headache disorders in primary care (2nd edition): on behalf of the European Headache Federation and Lifting The Burden: the Global Campaign against Headache. J Headache Pain 2019;20(1):57.
3. Silberstein SD. Considerations for management of migraine symptoms in the primary care setting. Postgrad Med 2016;128(5):523–37.
4. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018;38(1):1–211. 
5. Ailani J, Burch RC, Robbins MS. The American Headache Society Consensus Statement: update on integrating new migraine treatments into clinical practice. Headache 2021;61:1021–1039.
6. Eigenbrodt AK, Ashina H, Khan S. Diagnosis and management of migraine in ten steps. Nat Rev Neurol 2021;17:501–514.
7. Pérez-Muñoz A, Buse DC, Andrasik F. Behavioral Interventions for Migraine. Neurol Clin 2019;37(4):789–813.
8. Oskoui M, Pringsheim T, Holler-Managan Y, et al. Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2019;93(11):487–99. 
9. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies. Headache 2015;55(1):3–20.
10. Oskoui M, Pringsheim T, Billinghurst L, et al. Practice guideline update summary: Pharmacologic treatment of migraine for pediatric prevention: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2019;93:500–509.
11. Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012;78(17):1337–45.
12. Sacco S, Amin FM, Ashina M, et al. European Headache Federation guideline on the use of monoclonal antibodies targeting the calcitonin gene related peptide pathway for migraine prevention – 2022 update. J Headache Pain 2022;23:67.
13. Hepp Z, Dodick DW, Varon SF, et al. Persistence and switching patterns of oral migraine prophylactic medications among patients with chronic migraine: A retrospective claims analysis. Cephalalgia 2017;37:470–485.
14. Martelletti P, Schwedt TJ, Lanteri-Minet M, et al. My Migraine Voice survey: a global study of disease burden among individuals with migraine for whom preventive treatments have failed. J Headache Pain 2018;19:115.
15. Young WB. De-Stigmatizing Migraine - With Words: Headache. Headache: The Journal of Head and Face Pain 2018;58(2):319–21.
16. Hodge B. The Use of Symptom Diaries in Outpatient Care. FPM 2013;20(3):24–8. 

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