We searched PubMed with the keywords “migraine”, “treatment”, “randomized controlled”, and “trial”. All papers published from 1966 to November, 2009, in English or German, were considered if they described a controlled trial. Abstracts located by this search were reviewed and, if appropriate, the full articles obtained. References cited within selected articles were also considered. In addition, review books, abstracts, and articles that had previously come to the attention of the authors
ReviewCurrent practice and future directions in the prevention and acute management of migraine
Introduction
Migraine is a complex, common, and disabling disorder of the brain, whose mechanisms are only now being unravelled.1, 2, 3 It is characterised by sensory symptoms: pain and sensitivity to normal afferent information, such as light, sound, and head movement. The attack manifestations are defined by the International Headache Society,4 although the diagnostic criteria do not include common considerations such as the familial nature of the disorder.5 Migraine is one of the primary headache disorders in which headache is part of the clinical phenotype of the syndrome, in contrast to secondary headaches in which head pain is a consequence and a symptom of another disorder. Episodic migraine, by definition, occurs on fewer than 15 days per month and chronic migraine occurs on 15 days or more per month.6
In terms of acute treatment, migraine can be managed with available substance groups such as analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), ergotamine derivatives, and triptans, with their different modes of administration. New strategies in acute treatment are very promising and the calcitonin gene-related peptide (CGRP) receptor antagonists and serotonin 5-HT1F agonists are in the late stages of development. Preventive treatment can be divided into pharmacological and non-pharmacological therapies; one approach certainly does not exclude the use of the other, and a combination of pharmacological and non-pharmacological approaches, such as patient education, acupuncture, biofeedback, and exercise, can be useful in clinical practice. Medication-overuse headache (MOH),7 which is caused by the regular use of analgesics or specific anti-migraine treatments that can increase headache frequency, is very much a problem in migraine management.8
In this Review, the subject of migraine treatment alone is covered. A more detailed coverage of the pathophysiology and diagnosis of headache disorders can be found elsewhere.3, 9, 10, 11, 12, 13 Available and awaited future approaches to migraine treatment will be outlined and, where possible, the evidence base is cited, although many care strategies remain to be rigorously tested. We discuss both acute and preventive treatment, as well as strategies for the management of medication overuse.
Section snippets
General treatment principles
Once the diagnosis has been confirmed, one usually starts the management process by explaining the condition to provide an understanding of the problem and to set realistic expectations. This is helpful for patients because it engages them in their own care, which in turn facilitates management. A headache diary will often be very instructive in the planning and evaluation of therapy. Recording affected days, pain severity, and medication use and response, as well as obvious triggers (eg, days
Acute attack treatment
Current attack treatments fall into two categories: disease non-specific—analgesics and NSAIDS; and more disease specific—ergot-related compounds and triptans. Of note, specificity is relative, because triptans, for example, are also effective in the acute treatment of cluster headache,16 and perhaps other types of primary or even secondary headache.17, 18 To avoid medication overuse, patients need to be counselled on the frequency of use of acute attack medicines,19 and even simple analgesics
Preventive treatment
Preventive therapy is a crucial component of the management strategy to reduce migraine disability, and is indicated in about a third of patients with migraine.107 Unfortunately, the mechanisms of action of current preventive treatments are not well understood. One potential mechanism could be the suppression of CSD,80 as most preventive medicines seem to inhibit CSD.108 Silent CSD might occur during migraine without aura,109 and its suppression would explain the effectiveness of migraine
Alternative management strategies
Migraine is clearly an inherited disposition to headache that is triggered by change: too much or too little sleep, skipping meals, weather change, change in exertion patterns, or change in stress. Thus a balanced, regular lifestyle seems desirable, although it has not been proven by evidence-based medicine that education of patients and other adjustments to lifestyle truly reduce the frequency or severity of headaches. The same applies to the careful intake of recognised aggravating
Management of medication overuse
Medication overuse is effectively defined as the consumption of triptans, ergotamines, opioids, or combination analgesics on 10 days or more per month, with the International Headache Society allowing 15 days per month for simple analgesics.7 It seems essential that analgesic overuse should be reduced and eliminated to determine the underlying headache phenotype and to start managing the problem effectively.215 There is no universally accepted, evidence-based approach to the management of MOH.
Conclusions
Effective migraine management is possible in most patients. However, much work remains to be done to improve the evidence base of the current approaches, particularly in the management of chronic migraine, and to elucidate their mechanisms of action. Medical therapy is still the mainstay of migraine treatment, but migraine is a complex disorder for which comorbidities and patient preferences have to be taken into account. Non-pharmacological treatments can certainly help to reduce the disease
Search strategy and selection criteria
References (225)
Migraine
Lancet
(1998)- et al.
The effectiveness of combined oral lysine acetylsalicylate and metoclopramide compared with oral sumatriptan for migraine
Lancet
(1995) The pharmacology of headache
Progr Neurobiol
(2000)- et al.
Oral triptans (serotonin, 5-HT1B/1D agonists) in acute migraine treatment: a meta-analysis of 53 trials
Lancet
(2001) - et al.
Nitric oxide synthesis inhibition in migraine
Lancet
(1997) - et al.
Discovery of SB-705498: a potent, selective and orally bioavailable TRPV1 antagonist suitable for clinical development
Bioorg Med Chem Lett
(2006) - et al.
Selective serotonin 1F (5-HT1F) receptor agonist LY334370 for acute migraine: a randomised controlled trial
Lancet
(2001) - et al.
Efficacy and tolerability of MK-0974 (telcagepant), a new oral antagonist of calcitonin gene-related peptide receptor, compared with zolmitriptan for acute migraine: a randomised, placebo-controlled, parallel-treatment trial
Lancet
(2008) - et al.
The global burden of disease study—implications for neurology
Arch Neurol
(2000) Pathophysiology of migraine
The International Classification of Headache Disorders: 2nd edition
Cephalalgia
Prevalence and burden of migraine in the United States: data from the American Migraine Study II
Headache
New appendix criteria open for a broader concept of chronic migraine
Cephalalgia
The International Classification of Headache Disorders, 2nd edition (ICHD-II)—revision of criteria for 8.2 medication-overuse headache
Cephalalgia
Is medication-overuse headache a distinct biological entity?
Nat Clin Prac Neurol
Mechanism and management of headache
Chronic daily headache for clinicians
The headaches
Headache-Classification
Headache in clinical practice
An international study to assess reliability of the migraine disability assessment (MIDAS) score
Neurology
EFNS guideline on the drug treatment of migraine—report of an EFNS task force
Eur J Neurol
Trigeminal autonomic cephalalgias—diagnosis and treatment
Curr Neurol Neurosci Rep
The 5-HT1-like agonist sumatriptan has a significant effect in chronic tension-type headache
Cephalalgia
The headache of SAH responds to sumatriptan
Headache
Features of medication overuse headache following overuse of different acute headache drugs
Neurology
Efficacy of 1,000 mg effervescent acetylsalicylic acid and sumatriptan in treating associated migraine symptoms
Eur Neurol
Lysine-acetylsalicylic acid in acute migraine attacks
Eur Neurol
Efficacy and safety of acetaminophen in the nonprescription treatment of migraine
Arch Intern Med
Sumatriptan-naproxen for acute treatment of migraine: a randomized trial
JAMA
Sumatriptan and naproxen sodium for the acute treatment of migraine
Headache
Naproxen sodium in the treatment of migraine
Cephalalgia
A double-blind, randomized, placebo-controlled, single-dose study of the cyclooxygenase-2 inhibitor, GW406381, as a treatment for acute migraine
Eur J Neurol
Evaluation of a novel solubilized formulation of ibuprofen in the treatment of migraine headache: a randomized, double-blind, placebo-controlled, dose-ranging study
Cephalalgia
Efficacy of nonprescription doses of ibuprofen for treating migraine headache. A randomized controlled trial
Headache
Tolfenamic acid rapid release versus sumatriptan in the acute treatment of migraine: comparable effect in a double-blind, randomized, controlled, parallel-group study
Headache
Randomized, placebo-controlled trial of rofecoxib in the acute treatment of migraine
Neurology
Domperidone plus paracetamol in the treatment of migraine headache
Cephalalgia
A combination of ibuprofen lysine (IBL) and domperidone maleate (DOM) in the acute treatment of migraine: a double-blind study [abstract]
Cephalalgia
Comparison of a fixed combination of domperidone and paracetamol (domperamol) with sumatriptan 50 mg in moderate to severe migraine: a randomized UK primary care study
Curr Med Res Opin
A study to compare oral sumatriptan with oral aspirin plus metaclopramide in the acute treatment of migraine
Eur Neurol
Zolmitriptan versus a combination of acetlysalicylic acid and metaclopramide in the acute oral treatment of migraine: a double-blind, randomised, three-attack study
Eur Neurol
A double blind study of metoclopramide in the treatment of migraine attacks
J Neurol Neurosurg Psychiatry
Treatment of severe, disabling migraine attacks in an over-the-counter population of migraine sufferers: results from three randomized placebo-controlled studies of the combination of acetaminophen, aspirin and caffeine
Cephalalgia
Efficacy and safety of acetaminophen, aspirin, and caffeine in alleviating migraine headache pain—three double-blind, randomized, placebo-controlled trials
Arch Neurol
Caffeine as a risk factor for chronic daily headache: a population-based study
Neurology
Migraine—current understanding and treatment
N Engl J Med
Ergotamine in the acute treatment of migraine—a review and European consensus
Brain
Ergotamine and dihydroergotamine: history, pharmacology, and efficacy
Headache
Bioavailability of dihydroergotamine in man
Br J Clin Pharmacol
Cited by (192)
Transdermal delivery systems for migraine treatment: A gap to explore
2022, Journal of Drug Delivery Science and TechnologyCharacterization of opioidergic mechanisms related to the anti-migraine effect of vagus nerve stimulation
2021, NeuropharmacologyCitation Excerpt :Migraine is the second most common cause of disability globally (GBD Neurology Collaborators, 2019), with a burden on societies most productive age groups (Lipton et al., 2001). Although there are a range of treatments (Goadsby and Sprenger, 2010), and certainly new developments (Goadsby, 2019), there is considerable dissatisfaction with both acute (Lipton et al., 2019) and preventive therapies (Hepp et al., 2015). Neuromodulation approaches offer a combination of efficacy and tolerability that many patients find attractive (Puledda and Goadsby, 2017).
Herbal therapies for pain management: a scoping review of the current evidence
2024, Phytochemistry ReviewsThe Efficacy and Tolerability of the Use of Combined Versus Single Analgesic and Prophylactic Medications in Severe Migraine
2023, Jordan Journal of Pharmaceutical Sciences