MIGRAINE HEADACHE












  • * In children and adolescents, the headache may be 2 - 72 hours
  • Reference [6]
IHS Migraine Without Aura Criteria
A. At least five attacks fulfilling criteria B, C, and D
B. Headache attacks lasting 4 - 72* hours (untreated or unsuccessfully treated)
C. Headache has at least 2 of the following 4 characteristics:
  • Unilateral location (typically frontal and/or temporal region)
  • Pulsating quality
  • Moderate or severe pain intensity
  • Aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
D. At least one of the following during headache:
  • Nausea and/or vomiting
  • Sensitivity to light and sound

  • Reference [6,7]
IHS Migraine With Aura Criteria
Migraine headache with aura is a migraine headache (see above) that is preceded by the following:
A. At least 2 attacks fulfilling criteria B and C
B. One or more of the following fully reversible aura symptoms:
  • Visual - most common aura occurring in up to 90% of patients. Consists of scotomata (blind spots), simple flashes (phosphenes), specks, geometric forms, and shimmering in the visual field.
  • Sensory - second most common aura. Consists of "pins and needles" sensation affecting one side of the body, face, and/or tongue. Numbness may also occur.
  • Speech and/or language - less common. Marked by aphasia (inability to speak).
  • Motor - unilateral weakness. Also called hemiplegic migraine.
  • Brainstem - may include symptoms of dysarthria (difficulty speaking), vertigo, tinnitus, hearing impairment, double vision, ataxia, and decreased level of consciousness. Also called basilar migraine.
  • Retinal - monocular positive and/or negative visual phenomena (e.g. scintillations, scotomata, or blindness)
C. At least 2 of the following 4 characteristics:
  • At least one aura symptom spreads gradually over 5 minutes, and/or two or more symptoms occur in succession
  • Each individual aura symptom lasts 5 - 60 minutes
  • At least one aura symptom is unilateral
  • The aura is accompanied, or followed within 60 minutes, by headache (see above)


  • Reference [9]
MIGRAINE TRIGGERS
Food triggers
  • Alcohol
  • Caffeine
  • Chocolate
  • Monosodium glutamate - found in tomatoes, Parmesan cheese, potatoes, mushrooms, and certain cuisines (Korean, Japanese and Chinese)
  • Tyramine-containing foods - found in most cheeses, chocolate, alcoholic beverages, aged or smoked meats, and other fermented foods
  • Nitrate-containing foods - found in certain vegetables (celery, cress, chervil, lettuce, red beetroot, spinach)
Physiologic triggers
  • Too much or too little sleep
  • Skipped meals
  • Stress or post-stress
  • Menstruation
  • Fatigue
  • Physical activity
Environmental triggers
  • Loud noises
  • Weather changes
  • Perfumes or fumes
  • High altitude
  • Exposure to glare or flickering lights





  • See migraine headache medications for a review of triptans and ergotamines
  • Use a non-oral route if nausea and vomiting are intense
  • Reference [9]
AAFP-ACP Adult Migraine Treatment Recommendations
First-line therapies
  • Aspirin
  • Ibuprofen (Motrin®, Advil®)
  • Naproxen sodium (Aleve®)
  • Acetaminophen + aspirin + caffeine (Excedrin® migraine)
Second-line therapies
  • Migranal®
  • Oral naratriptan (Amerge®)
  • Subcutaneous or oral sumatriptan (Imitrex®)
  • Oral rizatriptan (Maxalt®)
  • Oral zolmitriptan (Zomig®)


Migraine treatment recommendations in children and adolescents
Children (4 - 12 years old)
  • First-line - Ibuprofen 7.5 - 10 mg/kg/dose every 6 - 8 hours. Do not exceed 400 mg/dose. Do not exceed 40 mg/kg/day.
  • Second-line - Acetaminophen 10 - 15 mg/kg/dose every 4 - 6 hours. Do not exceed 5 doses in 24 hours. Do not exceed 4000 mg/day
  • Third-line - triptans
    • Maxalt® (rizatriptan) - rizatriptan is FDA-approved for children 6 - 17 years
    • Imitrex® nasal spray (sumatriptan) - sumatriptan nasal spray has been studied in children as young as 8 years old
      • PMID 15037686 - sumatriptan nasal spray was given as a single dose in children 8 - 17 years old
        Dosing was as follows: 20 - 39 kg - 10 mg; ≥ 40 kg - 20 mg
Adolescents (> 12 years old)
  • First-line - Ibuprofen 200 - 400 mg every 4 - 6 hours. Do not exceed 1200 mg in 24 hours.
  • Second-line - Acetaminophen 650 mg every 4 - 6 hours. Do not exceed 3250 mg in 24 hours.
  • Third-line - triptans
    • Maxalt® (rizatriptan) - rizatriptan is FDA-approved for children 6 - 17 years
    • Axert® (almotriptan) - almotriptan is FDA-approved for adolescents 12 - 17 years
    • Imitrex® nasal spray (sumatriptan) - sumatriptan nasal spray has been studied in adolescents
      • PMID 15037686 - sumatriptan nasal spray was given as a single dose in children 8 - 17 years old.
        Dosing was as follows: 20 - 39 kg - 10 mg; ≥ 40 kg - 20 mg
      • PMID 11061765 - sumatriptan nasal spray was given as a single dose in children 12 - 17 years old.
        Dosing was 5, 10, and 20 mg.
      • PMID 16492230 - sumatriptan nasal spray was given as a single dose in children 12 - 17 years old.
        Dosing was 5 and 20 mg.



  • Reference [12,13,14,15]
  • AAP - American Academy of Pediatrics
Migraine Medications in Pregnancy
Medication Comment
Acetaminophen
  • Preferred agent if effective
  • Considered safe in all trimesters
Aspirin
  • Considered safe in first and second trimesters
  • Avoid in third trimester
Ibuprofen
Naproxen
  • Considered safe in first and second trimesters
  • Avoid in third trimester
Caffeine
  • Considered safe in all trimesters
Triptans
  • Sumatriptan (Imitrex®) has the largest amount of available data. Based on observational studies, it appears to be safe in pregnancy.
  • Rizatriptan (Maxalt®) and naratriptan (Amerge®) also appear to be safe, but there is less data for these two triptans.
  • See migraine headache medications for a review of triptans
Ergotamines
  • DO NOT USE

  • Reference [12,13,14,15]
  • AAP - American Academy of Pediatrics
Migraine Medications in Nursing
Medication Comment
Acetaminophen
  • Considered safe (AAP)
Aspirin
  • Associated with Reye's syndrome
  • Use caution (AAP)
Ibuprofen
Naproxen
  • Considered safe (AAP)
Caffeine
  • Considered safe (AAP)
Triptans
  • Sumatriptan - considered safe (AAP)
  • Naratriptan - probably safe
  • Rizatriptan - probably safe
Ergotamines
  • DO NOT USE



  • Reference [9,16,17]
Criteria for starting preventive therapy
In general, preventive medication is recommended for patients who meet any of the following criteria:
  • Two or more attacks per month that produce disability that lasts 3 or more days per month
  • Contraindication to, or failure of, acute treatments
  • Use of abortive medication more than twice per week
  • The presence of uncommon migraine conditions, including hemiplegic migraine, migraine with prolonged aura, or migrainous infarction [9]
Medications that are proven effective in preventing migraine
Medication Dosing
Valproic acid (Depakote®)
Topiramate (Topamax®)
  • Starting: 25 mg in the evening
  • Target dose: 50 mg twice a day
  • Increase daily dose by 25 mg at weekly intervals
  • See topiramate for more
Propranolol (Inderal®) Standard-release
  • Starting: 80 mg/day
  • Maintenance: 160 - 240 mg/day
  • Give in 2 - 3 divided doses
  • See beta blockers for more
Extended-release
  • Starting: 80 mg once daily
  • Maintenance: 160 - 240 mg once daily
Metoprolol (Toprol®)
  • 150 - 200 mg/day
  • Titrate dose over several weeks
  • See beta blockers for more
Timolol
  • Starting: 10 mg twice a day
  • Maintenance: 10 - 30 mg/day
  • Maximum: 30 mg/day
  • 20 mg/day dose may be given as single daily dose
  • See beta blockers for more
Petasites
(butterbur plant extract)
  • 50 - 75 mg twice a day
  • Petasites is a herbal extract from the butterbur plant
  • Found effective in these two studies - PMID 15623680, PMID 11020030
Erenumab (Aimovig®)
Medications that are probably effective in preventing migraine
Amitriptyline
Venlafaxine (Effexor XR®)
Atenolol (Tenormin®)
Nadolol (Corgard®)


  • Reference [7]
Medications for preventing migraines in children and adolescents
Medication Dosing and study
Valproic acid (Depakote®)
Topiramate (Topamax®)
  • Starting dose was 15 mg/day. Dose was titrated over an 8 week period to a target of 2 - 3 mg/kg/day. (ages 6 - 15)
  • Dosing based on PMID 16324162
  • See topiramate for more
Amitriptyline
Cyproheptadine
  • 2 - 6 years: 2 mg two to three times a day (max 12 mg/day)
  • 7 - 14 years: 4 mg two to three times a day (max 16 mg/day)
  • Dosing is from package insert
  • Dosing based on PMID 15012660
Propranolol


Medications for preventing menstrual migraine
Medication Dosing and study
Frovatriptan (Frova®)
  • 2.5 mg once or twice daily for 6 days starting 2 days before anticipated headache
  • Dosing based on PMID 15277618
Naratriptan (Amerge®)
  • 1 mg twice daily for 5 days starting 2 days before anticipated onset of menses
  • Dosing based on PMID 11264684
Zolmitriptan (Zomig®)
  • 2.5 mg two to three times daily for 7 days starting 2 days before anticipated onset of menses
  • Dosing based on PMID 18788838


  • Reference [12,13,14,15]
  • AAP - American Academy of Pediatrics
Preventive therapies in pregnancy
Propranolol
Metoprolol
  • Preferred agents
  • Use lowest effective dose
  • Stop 2 - 3 days before delivery to reduce risk of fetal bradycardia and reduction in uterine contractions
Amitriptyline
  • Considered safe at lower doses (10 - 50 mg/day)
  • When possible, taper 3 -4 weeks before delivery
Aspirin
  • Low-dose aspirin (75 mg/day) is considered safe in the first and second trimester
  • Do not use in third trimester

  • Reference [12,13,14,15]
  • AAP - American Academy of Pediatrics
Preventive therapies in nursing
Propranolol
Metoprolol
  • Propranolol - considered safe (AAP)
  • Metoprolol - considered safe (AAP)
Amitriptyline
  • Effect unknown but may be of concern (AAP)
Aspirin
  • Associated with Reye's syndrome
  • Use caution (AAP)