Standards of Care for Headache Diagnosis and Treatment

According to the American Migraine Prevalence and Prevention (AMPP) Study1, more than 29 million Americans experience migraines, yet only about 48 percent who have the symptoms of migraine actually receive proper diagnosis. Migraine is a chronic neurologic disorder characterized by recurring attacks of head pain and associated symptoms such as dizziness, nausea, vomiting or extreme sensitivity to light and sound. Below is an overview of the National Headache Foundation’s (NHF) Standards of Care for Headache Diagnosis and Treatment which include the U.S. Headache Consortium’s recommendations for the proper diagnosis of and treatment options for migraine.

Types of Migraine

The most common types of migraine seen in primary care settings are migraine without aura, migraine with aura, and probable migraine. Migraine without aura (no visual, auditory or other sensory symptoms prior to a migraine attack) begins as a dull ache and develops into a constant throbbing and pulsating pain often felt on one side of the head which can sometimes generalize to other areas. The pain is usually accompanied by a combination of nausea, vomiting, and sensitivity to light and noise. Migraine with aura includes the same symptoms as migraine without aura but is also accompanied by triggers before the headache begins, including visual or auditory hallucinations and disruptions in smell (such as strange odors), taste or touch. Probable migraine is a term used to diagnose someone who lacks one of the diagnostic criteria for migraine but experiences other symptoms of migraine.

Diagnosis of Migraine

Healthcare providers should evaluate the following symptoms to determine if a patient has migraine:

  • Visual distortions such as blind spots, flashes of light and zigzag lines
  • Motor weakness
  • Disruption to sensory symptoms such as smell, taste or touch
  • Temporary loss of ability to speak or understand speech
  • Temporary lack of coordination or control of arms and legs
  • Vertigo
  • Unilateral headache pain
  • Pulsating headache
  • Aggravation of headache by routine physical activity
  • Nausea and/or vomiting
  • Sensitivity to light and/or sound
  • Moderate to severe pain intensity

Migraine Treatment Strategy

The goal with any acute migraine treatment is to provide rapid resolution of migraine attacks, while controlling the quantities of medication used and preventing the development of chronic headaches. Specifically, the U.S. Headache Consortium has developed the following goals for acute migraine treatment:

  • Treat attacks rapidly and consistently and prevent recurrence
  • Restore the patient’s ability to function
  • Minimize the use of backup and rescue medications (medications used to relieve symptoms of migraine when acute therapy does not work)
  • Optimize self-care and reduce subsequent use of resources
  • Be cost-effective in overall management
  • Have minimal or no adverse events

In determining the best treatment to accomplish these goals, the U.S. Headache Consortium recommends using a stratified treatment approach. A stratified treatment approach bases treatment on several factors, including pain intensity, degree of disability, comorbidity (the presence of one or more diseases or disorders), presence of nausea and vomiting, previous treatment(s) and personal preferences. For example, patients with mild to moderate attacks may benefit from the use of non-steroidal anti-inflammatory drugs (NSAIDs) or combination analgesics, while someone who experiences severe attacks may find triptans more effective. Healthcare professionals should discuss with migraine sufferers how best to customize migraine treatment as well as the proper and responsible use of medication and how and when to use rescue medications, if appropriate.

Acute Migraine Treatments

Acute migraine medications are designed to either stop a migraine attack after it begins or alleviate the pain and symptoms of migraine. There are several classes of acute medications that healthcare professionals may prescribe to treat migraines, including non-opioid analgesics, opioid analgesics, ergot derivatives, triptans and rescue medications.

Non-opioid Analgesics

Non-opioid analgesics are pain relievers that do not contain narcotics, or opioids. Many patients with mild to moderate headaches will often respond favorably to simple analgesics, such as aspirin or acetaminophen. Sometimes simple analgesics are combined, which may offer several advantages, such as enhanced pain relief, reduced side effects and convenience. Non-opioid analgesics include non-steroidal anti-inflammatory drugs (NSAIDs), which not only relieve pain, but also reduce the inflammation that often accompanies pain. Examples of non-opioid analgesics include ibuprofen and naproxen sodium.

Opioid Analgesics

Opioid analgesics (narcotics), the most powerful analgesics, refer to all medications with morphinelike activity used to relieve pain. Opioids may be prescribed migraine treatment because they are so effective in controlling pain. Opioids are not appropriate for everyone and should be reserved for patients with moderate to severe pain who do not respond to non-opioid medications. General guidelines for opioids limit use to no more than three days per week. Opioid analgesics used to treat migraines include butorphanol, codeine and methadone.

Ergot Derivatives

Ergot derivatives are medications that work by constricting blood vessels in the body and are used to treat severe, throbbing headaches. Because ergot derivatives can cause serious side effects, they should only be prescribed to patients who do not respond to analgesics or who experience significant side effects from other migraine medications. Ergot derivatives will not relieve any pain other than throbbing headaches. Examples of ergot derivatives include ergotamine and DHE.

Triptans

Triptans, also known as selective serotonin receptor agonists, work by stimulating serotonin, a neurotransmitter found in the brain, to reduce inflammation and constrict blood vessels, thereby stopping the migraine. Triptans are approved by the U.S. Food and Drug Administration for the treatment of migraines and should be considered first-line treatment for most migraine attacks, other than for those patients who respond to analgesics or combination agents or for whom triptans are not medically indicated. Triptans have been shown to be effective in relieving headache pain, as well as nausea and light sensitivity. Medications in the triptan class include sumatriptan, frovatriptan and naratriptan, eletriptan, zolmitriptan, rizatriptan and almotriptan.

Rescue Medications

In some instances, an acute medication may produce an ineffective outcome and therefore a rescue treatment is needed. A rescue therapy is a medication that people with migraines can use at home for pain relief when other medications fail, such as NSAIDs or opioids. A treatment plan including a rescue strategy should be discussed and implemented during a routine visit to a healthcare provider to avoid any emergencies. Many medications can be considered as rescue treatments; however, if rescue therapy is required regularly (that is, more than twice a month), speak to a healthcare provider to find a more effective first-line acute medication or to discuss possible preventive medications.

Preventive Migraine Treatments

Many people who experience migraines are effectively treated by taking acute medications or making lifestyle modifications, such as reduction of migraine stimulants and trigger avoidance. However, preventive medications, or medications taken on a daily basis whether or not a migraine is present, may be necessary if a migraine patient:

  • Frequency of headache ≥ 2 per month with disability ≥ 3 days per month
  • Recurring migraines that, in the patient’s opinion, significantly interfere with daily routines
  • Use of acute medication more than 2 times a week
  • Acute medications are contraindicated, not tolerated, or are ineffective

In determining the best preventive approach for treating migraine, the U.S. Headache Consortium recommends three treatment strategies: episodic, short-term and chronic. Episodic treatment is employed if a headache trigger is known, so that a headache can be treated prior to the known trigger. A short-term treatment is used when exposure to a headache trigger is time-limited, such as flying or menstruation. Chronic treatment is best for long-term migraine needs. There are several classes of preventive medications available that healthcare professionals may prescribe to prevent migraines, including beta-blockers, antidepressants, calcium antagonists, neurostabilizers and non-steroidal agents.

Preventive treatments should be started at low doses and increased slowly so that the maximum potential of the treatment may be realized. It is important to note that preventive medications are considered effective if the frequency of attacks is reduced by 50 percent or more.

Beta-Blockers

Beta-adrenergic blockers, also known as beta blockers, work by affecting the response to some nerve impulses in certain parts of the body and are thought to prevent headaches by improving blood flow. They are the most thoroughly studied and widely used of all migraine preventive agents. Beta-blockers used to treat migraines include propranolol and timolol, which are both approved by the FDA for migraine prevention.

Antidepressants

Antidepressants are widely prescribed for migraine prevention because they are thought to regulate serotonin levels, a chemical messenger in the brain that influences migraine. Tricyclic antidepressants are efficacious in the prevention of migraine while non-tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) are also prescribed for the prevention of migraine. Common antidepressants prescribed for the prevention of migraine include amitriptyline, nortriptyline, and fluoxetine.

Calcium Antagonists

Calcium antagonists, also known as calcium-channel blockers, improve blood flow by reducing the narrowing of blood vessels, therefore preventing headaches involving blood vessels. They are generally prescribed because of limited adverse events but do not possess the established efficacy of other preventive drug classes. Examples of calcium antagonists include verapamil and nimodipine.

Neurostabilizers

Although relatively new in migraine prevention, neurostabilizers, or antiepileptic drugs, have demonstrated efficacy through controlled clinical trials. Neurostabilizers are used as a migraine treatment because epilepsy and migraine have been found to be caused by similar reactions in the brain. Examples of FDA approved neurostabilizers used for the treatment of migraine include topiramate, divalproex sodium and timolol maleate.

Non-steroidal Agents

In addition to acute migraine treatment, non-steroidal anti-inflammatory drugs (NSAIDs), both over-the-counter and prescription medications, have also proven somewhat effective in migraine prevention. It is not yet known how these drugs may reduce attack frequency. Examples of NSAIDs used for preventive treatment include ibuprofen, naproxen sodium and celecoxib.

Special Considerations in Migraine Treatment

Overuse

Some patients with frequent disabling headaches may overuse their acute medication, leading to chronic daily headache and growing dependence on the medication. Migraine sufferers who overuse medication may also become resistant to preventive medications. Medication overuse can be avoided by strictly adhering to prescribed doses of acute medication. Overuse can occur in the treatment of migraine with almost all analgesics, opioids, ergotamines, caffeine, or triptans.

Treatment without medication

Treatments that do not involve medication are often added to existing prescribed drug treatments. Particularly at the early onset of migraine, non-medication techniques may eliminate the need for medication. Non-medication treatments commonly used in migraine relief are relaxation, biofeedback, guided visualization and diaphragmatic breathing. Regular exercise, maintaining regular sleep and meal schedules, and practicing overall good health strategies are also an important part of the treatment regimen but are more effective as preventives than as treatments.

Co-pharmacy

A combination of existing treatments for migraine may be considered when patients do not experience relief from one medication. A healthcare provider should be consulted to decide if a combination of treatments is safe and effective.

*Many of the recommended treatments for migraine are not approved by the U.S. Food and Drug Administration (FDA) specifically for the treatment of migraine. However, their use in the treatment of migraine may be supported by scientific research and clinical experience. Consult with your healtahcare professional to determine the best approach to treating your migraine.