Diagnosis and

Management
Definition of Migraine
• Migraine is a primary headache disorder
• characterized by recurrent attacks of moderate to severe headache
• often associated with nausea, photophobia, and phonophobia
• with or without aura.

(Source-Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache
Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018;38(1):1–211.)
Diagnosis of Migraine
Requires a systematic approach
• Record medical history
• Apply diagnostic criteria
• Consider differential diagnoses
• Examine patient to exclude other causes
• Use neuroimaging only when a secondary headache disorder is
suspected
Diagnostic criteria for primary
headache disorders(ICHD-3)
A. Migraine Without Aura
At least five attacks that fulfill criteria below
1. Headache attacks lasting 4–72 hours (when untreated or unsuccessfully
treated
2. Headache has at least two of the following four characteristics:
• Unilateral location
• Pulsating quality
• Moderate or severe pain intensity
• Aggravation by, or causing avoidance of, routine physical activity (e.g., walking or
climbing stairs)
3.During the headache, at least one of the following:
• Nausea and or vomiting.
• Photophobia and phonophobia

4. Not better accounted for by another ICHD-3 diagnosis

Source: ICHD-3. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia. 2018;38(1):1–
211.
B. Migraine with Aura
1. At least two attacks that fulfil criteria 2 and 3
2. One or more of the following fully reversible aura symptoms: -
visual
• sensory
• speech and/or language
• motor
• brainstem
• retinal
3. At least three of the following six characteristics:
• at least one aura symptom spreads gradually over ≥5 min
• two or more aura symptoms occur in succession
• each individual aura symptom lasts 5–60 min
• at least one aura symptom is unilateral
• at least one aura symptom is positive
• the aura is accompanied with or followed by headache within 60 min
4. Not better accounted for by another ICHD-3 diagnosis

(Source:Diagnosis and management of migraine in ten steps- Nature neurology, ICHD-3)

C. Chronic Migraine
1. Headache (migraine-like or tension-type-like) on ≥15 days/month for >3
months that fulfil criteria 2 and 3
2. Attacks occur in an individual who has had at least five attacks that fulfil
the criteria for migraine without aura and/or for migraine with aura
3. On ≥8 days/month for >3 months, any of the following criteria are met:
• Criteria 3 and 4 for migraine without aura
• Criteria 2 and 3 for migraine with aura
• Believed by the patient to be migraine at onset and relieved by a triptan
or ergot derivative
4. Not better accounted for by another ICHD-3 diagnosis

Source: (Headache Classification Committee of the International Headache Society (IHS). The International
Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018;38(1):1–211.)
Red Flags for Headache
Used to rule out secondary causes of headache:
SNOOP4 Criteria
• S: Systemic symptoms or illness (fever, weight loss)
• N: Neurologic signs/symptoms (confusion, focal deficit)
• O: Onset is sudden (thunderclap headache)
• O: Older age at onset (>50 years)
• P: Pattern change (progressive, new type)
• P :Positional headache
(worse when lying down or standing up)
• P :Precipitated by Valsalva maneuver
• (e.g., triggered by coughing, sneezing, or exertion)
• P :Papilledema
(suggests increased intracranial pressure)

(Source: Red and orange flags for secondary headaches in clinical practice; AAN/ Clinical availability of SNOOP4 in acute non-traumatic headache
patients admitted to the emergency department-HKJEM-2020
Abortive Therapies
A. First-Line Medications
NSAIDs:
• Aspirin: 900–1,000 mg oral
▸ Contraindicated in GI bleeding, heart failure
• Ibuprofen: 400–600 mg oral
• Diclofenac potassium: 50 mg oral (soluble)
Simple Analgesic:
• Paracetamol: 1,000 mg oral
▸ Avoid in hepatic disease, renal failure
Antiemetics (as needed):
• Domperidone: 10 mg oral/suppository
▸ Avoid in GI bleeding, epilepsy, renal failure, arrhythmia
• Metoclopramide: 10 mg oral
▸ Avoid in Parkinson’s, epilepsy, mechanical ileus

(Source:Diagnosis and management of migraine in ten steps)

B. Second-Line Medications
(Triptans)
• Sumatriptan: 50–100 mg oral, 6 mg SC, 10–20 mg nasal
Avoid in CV disease, uncontrolled HTN, hemiplegic/basilar migraine
• Zolmitriptan: 2.5–5 mg oral, 5 mg nasal
• Almotriptan: 12.5 mg oral
• Eletriptan: 20-80 mg oral
• Frovatriptan: 2.5mg oral
• Naratriptan: 2.5mg oral
• Rizatriptan: 10 mg oral or ODT ( 5 mg if on propranolol)
C. Third-Line Medications
• Gepants:
• Ubrogepant: 50 or 100 mg oral
Avoid with strong CYP3A4 inhibitors
• Rimegepant: 75 mg oral
▸ Avoid in hepatic impairment, allergy
• Ditans:
• Lasmiditan: 50–200 mg oral
▸ Avoid in pregnancy, with P-gp substrate drugs
Drug Type Example Cost Availability Efficacy Notes

NSAIDs Naproxen Low High Moderate First-line

Triptans Sumatriptan Medium Good High Avoid in CVD

Gepants Ubrogepant High Limited High No

vasoconstriction
Ditans Lasmiditan High Limited Moderate CNS side effects
Indications for Migraine
Prevention
• Migraines ≥4 days/month
• Severe, disabling attacks
• Poor response or side effects from acute meds
• Attacks lasting >72 hours
• Patient prefers prevention
• Comorbid anxiety or depression
• Overuse of acute meds (>10 days/month)

Source:Headache Classification Committee of the International Headache Society (IHS),

The International Classification of Headache Disorders,
3rd edition (beta version)
Goals of Migraine Prevention

• Reduce frequency, severity, duration, and disability of attacks

• Improve response to acute treatment and avoid escalation
• Enhance overall function and reduce disability
• Decrease reliance on poorly tolerated, ineffective, or unwanted acute treatments
• Lower the overall cost of migraine treatment
• Empower patients to manage their condition and increase personal control
• Improve health-related quality of life (HRQoL)
• Reduce headache-related distress and psychological symptoms

(Source:The American Headache Society Position Statement OnIntegrating New Migraine Treatments Into Clinical Practice;AHS-2018)
 Preventive Migraine Treatment
First Line Medications
Drug Class Drug Dosage and Route Contraindications

Beta-blockers Atenolol 25–100 mg oral twice daily Asthma, cardiac failure, Raynaud
disease, AV block, depression

Bisoprolol 5–10 mg oral once daily Same as above

Metoprolol 50–100 mg oral twice daily or 200 Same as above

mg modified-release once daily

Propranolol 80–160 mg oral once or twice daily Same as above

(long-acting)

Angiotensin II receptor blocker Candesartan 16–32 mg oral per day Co-administration with aliskiren

Anticonvulsant Topiramate 50–100 mg oral daily Nephrolithiasis, pregnancy,

lactation, glaucoma
 Second-Line Preventive Medications
Drug Class Drug Dosage and Route Contraindications

Tricyclic antidepressant Amitriptyline 10–100 mg oral at night Age <6 years, heart failure, use
with MAOIs/SSRIs, glaucoma

Calcium antagonist Flunarizine 5–10 mg oral once daily Parkinsonism, depression

Anticonvulsant Sodium valproate 600–1,500 mg oral once daily Liver disease, thrombocytopenia,
women of childbearing potential
 Third-Line Preventive Medications
Drug Class Drug Dosage and Route Contraindications

Botulinum toxin OnabotulinumtoxinA 155–195 units injected to 31–39 Infection at injection site
sites every 12 weeks

CGRP monoclonal antibodies Erenumab 70 or 140 mg subcutaneous once Hypersensitivity; not recommended
monthly in stroke, SAH, CHD, IBD, COPD,
poor wound healing

Fremanezumab 225 mg subcutaneous monthly or Same as above

675 mg quarterly

Galcanezumab 240 mg loading dose, then 120 mg Same as above

subcutaneous monthly

Eptinezumab 100 or 300 mg intravenous Same as above

quarterly
Treatments With Evidence of Efficacy in Migraine
Prevention
Level of Evidence Drug Class Medications Notes
Established Efficacy Antiepileptic drugs Divalproex sodium, Valproate Not recommended for women of
sodium, Topiramate childbearing potential not using
contraception

Beta-blockers Metoprolol, Propranolol, Timolol

Antidepressants Amitriptyline C/I: age<6 years,heartfailure, co-
administration with MAOI and
SSRIs
Other OnabotulinumtoxinA Approved for chronic migraine
Probably Effective Antidepressants Venlafaxine
Beta-blockers Atenolol, Nadolol
ACE inhibitors Lisinopril
Angiotensin receptor blockers Candesartan C/I: Co- administration of aliskiren
(ARBs)
Possibly Effective Beta-blockers Nebivolol, Pindolol
Antiepileptic drugs Carbamazepine
Alpha-agonists Clonidine, Guanfacine
Antihistamines Cyproheptadine
Triptans Frovatriptan For short-term prevention of
menstrual migraine
(Source:The American Headache Society Position Statement OnIntegrating New Migraine Treatments Into Clinical Practice;AHS-2018)
Duration of Preventive Medication Use

• Trial period: 2–3 months to assess effectiveness

• Evaluate response: Continue if significant improvement
• Long-term use: Months to years if effective and well-tolerated
• Monitor for overuse: Prevent medication overuse headaches
• Adjust as needed: Switch or modify if no response or side effects

Source:Headache Classification Committee of the International Headache Society (IHS),

The International Classification of Headache Disorders,
3rd edition (beta version)
Migraine Triggers & Lifestyle Factors
Common Migraine Triggers
• Sleep disturbances (too much/little sleep, poor quality)
• Dietary factors (skipping meals, caffeine, alcohol, smoking,MSG)
• Stress and emotional triggers
• Hormonal changes (especially in women, perimenstrual)
• Environmental (bright lights, strong smells, weather changes)
• Sensory stimuli (noise, screens, flickering lights)

(Lifestyle Modifications for Migraine Management; frontiers in neurology-minireveiw-2022)

Pharmacological vs Non-
pharmacological
• Non-pharmacological therapies effectively reduce migraine
frequency.
• Comparable efficacy: No significant difference in monthly migraine
days between drug and non-drug treatments.
• Suggests both approaches are viable options in migraine
management.

(Source: Comparative Effectiveness of Pharmacological versusNon-pharmacological Interventions for Migraine Management:A Meta-
analysis)
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