#migraineawareness2021
How to treat migraine?
Current therapies for migraine include acute medications, preventive medications, and non-pharmacologic therapies. It should be emphasized that medication therapy is the mainstay of migraine care since there is limited evidence to support broader use of non-pharmacologic therapies.
Acute medications are, as the name implies, used to treat acute migraine attacks and should be taken early in the headache phase when pain is still mild. This improves chances of therapeutic success, but caution is needed to avoid regular overuse which can contribute to the development of medication-overuse headache. It is recommend that all patients with migraine be offered acute medications.
Acute medications with evidence-based effectiveness include non steroidal anti-inflammatory drugs, triptans, gepants, and ditans, whereas opioids, barbiturates and oral ergot alkaloids are considered medications to avoid. Antiemetics are useful oral adjuncts for patients who experience nausea and/or vomiting during migraine attacks.
Migraine care often begins with self-management. Indeed, some people with migraine can self-manage with the use of non steroidal anti-inflammatory drugs (e.g. ibuprofen, aspirin, diclofenac potassium) that are sold as over-the-counter analgesics. If self-management provides insufficient pain relief, migraine care should be initiated and maintained in primary care for most people with migraine. Primary care practitioners can establish the diagnosis of migraine based on the medical history, exclude secondary causes, and use evidence-based treatment algorithms. Referral to specialist care should be limited to people whose migraine is diagnostically challenging, difficult to treat, or complicated by comorbidities. For example, it is recommended that people with chronic migraine are referred to specialist care.
Preventive medications target the reduction of migraine frequency, duration, and/or pain intensity. Initiation of preventive therapy is decided on a case-by-case basis, but is commonly recommend for patients whose migraine continues to impair their quality of life despite optimized use of acute medications. A further indication for preventive therapy is overuse of acute medication.
For years, migraine preventive options have been geared toward medications created for other conditions but shown to be safe and effective for migraine. These include antidepressants, antihypertensives, anticonvulsants, and onabotulinumtoxinA. Now, a new class of migraine-specific preventive medications have emerged that target signaling molecule CGRP or its receptor. In many countries, regulatory restrictions limit the use of onabotulinumtoxinA and CGRP-targeted therapies to people with migraine in whom other preventive medications have failed or are contraindicated. It should be noted that these restrictions are due to onabotulinumtoxinA and CGRP-targeted therapies being more expensive and less accessible, compared with off-label use of antidepressants, antihypertensives, and anticonvulsants.
Non-pharmacologic therapies can also be used for migraine care, either as adjuncts to acute and preventive medications or instead of them if medication use is contraindicated. Some evidence does support the use of non-invasive neuromodulatory devices. Biobehavioral therapy can also be another option to consider in eligible patients.
Last but certainly not least, lifestyle changes can benefit people with migraine who have a poor quality of sleep, high levels of stress, and/or physical fitness, though any changes should not result in unnecessary avoidance behavior.

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