Annals of Internal Medicine䊛

In the Clinic®

Migraine
Risk and Prevention

M
igraine affects around 15% of adults in
the United States and accounts for
more than 90% of patients with recur-
rent headache presenting to primary care of- Diagnosis
fices and emergency departments. Diagnostic
uncertainty increases the likelihood of unneces-
sary investigations and suboptimum manage- Treatment
ment. This In the Clinic advises clinicians on
diagnosing migraine and avoiding diagnostic
mistakes, informing patients who want more Follow-up
self-management and nondrug interventions,
selecting drugs to treat migraine and prevent
attacks, and deciding when to refer the patient Practice Improvement
to a specialist.

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Physician Writer doi:10.7326/AITC201704040

E. Anne MacGregor, MB BS,
MD CME Objective: To review current evidence for risk, prevention, diagnosis, treatment,
follow-up, and practice improvement of migraine.
Funding Source: American College of Physicians.
Disclosures: Dr. MacGregor, ACP Contributing Author, reports personal fees from Menarini
outside the submitted work. Disclosures can also be viewed at www.acponline.org/authors
/icmje/ConflictOfInterestForms.do?msNum=M17-0193.
With the assistance of additional physician writers, the editors of Annals of Internal
Medicine develop In the Clinic using MKSAP and other resources of the American
College of Physicians.
In the Clinic does not necessarily represent official ACP clinical policy. For ACP clinical
guidelines, please go to https://www.acponline.org/clinical_information/guidelines/.
© 2017 American College of Physicians

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 More than 90% of patients with
recurrent headache who present
to primary care offices or emer-
gency departments have migraine.
It affects approximately 15% of
U.S. adults and is associated with
high socioeconomic and personal
Risk and Prevention
Who is at increased risk for
migraine?
Studies have shown that the ten-
dency toward migraine can be
inherited—if one parent has mi-
graine, there is a 40% chance that
the child will have migraine; if both
parents have migraine, there is a
75% chance. Migraine onset usu-
ally begins in late childhood or
early adolescence and follows vari-
ous courses: The headache may
go into remission after a few years,
recur in cycles of variable head-
ache activity for many years or de-
cades, or evolve into a chronic and
Diagnosis
What clinical features are
required for a diagnosis of
migraine?
A typical migraine attack consists
of a unilateral, throbbing head-
ache accompanied by photopho-
bia, phonophobia, nausea, and
disability (see the Box: Interna-
tional Headache Society Criteria
for Migraine Diagnosis).
Migraine is preceded by focal
neurologic symptoms, termed
“aura,” in up to 30% of patients.
Aura is typically characterized by
any combination of visual, hemi-
sensory, or language abnormali-
ties, with each symptom develop-
ing over at least 5 minutes and
lasting a maximum of 60 minutes.
The most common aura is visual,
consisting of a flashing light or an
enlarging blind spot rimmed with
a shimmering edge or jagged
lines in the peripheral vision.
Common nonvisual auras include
姝 2017 American College of Physicians ITC50 In the Clinic
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impact. In the Global Burden of
Disease Study 2015, migraine was
the seventh most prevalent spe-
cific cause of years lived with dis-
ability worldwide for all ages and
the third most prevalent for ages
15– 49 years.
more refractory state (in a few pa-
tients). Migraine is more common
in preadolescent boys than girls
but becomes 3 times more com-
mon in women than men. Preva-
lence peaks in the fifth decade of
life, decreases significantly in the
sixth and seventh decades, and is
rare in later decades.
Can migraine be prevented in
patients at increased risk?
Although the natural history of mi-
graine cannot be changed, early
diagnosis and management im-
prove the long-term prognosis.
spreading unilateral numbness
or tingling affecting the face and
arm and disturbed thinking or
speech. The associated head-
ache usually occurs within 1 hour,
but some auras do not progress
to headache.
The 5 criteria most predictive of
migraine may be remembered
more easily by the mnemonic
“POUND,” as in “pounding
headache”:
•Pulsatile quality (headache de-
scribed as pounding or throbbing)
•One-day duration (episode of
headache lasts 4 –72 hours if
untreated)
•Unilateral location
•Nausea or vomiting
•Disabling intensity (altered
usual daily activities during
headache episode)
Annals of Internal Medicine 4 April 2017

International Headache Society
Criteria for Migraine Diagnosis*
Without aura
A. ≥5 attacks in a lifetime fulfilling
criteria B–D
B. Headache attacks lasting 4 –72 h
(untreated or unsuccessfully
treated)
C. Headache has ≥2 of the
following 4 characteristics:
1. Unilateral location
2. Pulsating quality
3. Moderate or severe pain
intensity
4. Aggravated by or causing
avoidance of routine physical
activity (e.g., walking or climb-
ing stairs)
D. During headache, occurrence
of ≥1 of the following symptoms:
1. Nausea and/or vomiting
2. Photophobia and phonophobia
E. Not better accounted for by an-
other ICHD-3 diagnosis
With typical aura
A. ≥2 attacks in a lifetime fulfilling
criteria B and C
B. Aura consisting of visual, sen-
sory, or speech/language symp-
toms, each fully reversible, but no
motor weakness or brainstem
symptoms†
C. ≥2 of the following 4
characteristics:
1. ≥1 aura symptom spreads
gradually over ≥5 min, and ≥2
symptoms occur in succession
2. Each individual aura symptom
lasts 5– 60 min
3. ≥1 aura symptom is unilateral
4. Aura accompanied or fol-
lowed within 60 min by
headache
D. Not better accounted for by
another ICHD-3 diagnosis, and
transient ischemic attack has been
excluded
ICHD = International Classifica-
tion of Headache Disorders.
* Adapted from Headache Classifica-
tion Committee of the International
Headache Society (IHS). The Interna-
tional Classification of Headache Dis-
orders, 3rd edition (beta version).
Cephalalgia. 2013;33:629-808, with
permission.
† Dysarthria, vertigo, tinnitus, hyp-
acusis, diplopia, ataxia, decreased
level of consciousness.
4 April 2017 Annals of Internal Medicine
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A study of the International Headache Society
criteria for the diagnosis of migraine showed Symptoms Suggesting Serious
that specificity was excellent but sensitivity Secondary Causes of Headache
was <50%, which could be due to their restric- Change in previously existing
tive nature. Using the 5 criteria most predictive headache (intensity,
of migraine resulted in a sensitivity of 95% frequency, pattern)
and a specificity of 78%. The presence of 3 of Daily or continuous headache
the 5 criteria is predictive of migraine, and 4 of Effort-related or positional
5 is highly predictive (1). headache
Headache associated with change
What clinical features are
in personality or mental status
helpful in distinguishing Headache brought on by
migraine from tension-type coughing, sneezing, or
headache? bending
Headache brought on by exercise
Tension-type headache lacks the
or orgasm
characteristic symptoms of nau-
Headache causing awakening
sea and disability that define mi-
from sleep
graine. These headaches are typ-
Headache that becomes refractory
ically bilateral, lasting from 30 to previously effective
minutes to 7 days. The nonpul- treatment
sating pressing or tightening Jaw pain (claudication)
quality is described by patients Migraine aura that begins or
as a “band-like” constriction persists after the headache
around the head. The attacks are has dissipated
New onset after age 50 y
mild to moderate in intensity, do
not prohibit activity, are not ag- Persistent pain on 1 side of the
head without contralateral
gravated by routine physical ac-
attacks (“side-locked”)
tivity, and are not associated with
Previous head trauma
nausea or vomiting (although
Rapidly increasing headache
anorexia may occur). Photopho- frequency
bia or phonophobia may be Subjective numbness or tingling
present. However, extensive vari- inconsistent with sensory
ability in the clinical expression of aura of migraine
migraine often leads to misdiag- Sudden explosive onset of head-
nosis of tension headache in the ache with rapid progression
over seconds to minutes
presence of bilateral steady pain
Worsens with Valsalva maneuver
or sinus headache, when the
Worst headache of life
discomfort is frontal or facial
pressure.
What clinical features suggest
that the cause of headache may
be more serious than migraine?
More serious causes of head-
ache (Table 1) must always be
considered because certain
conditions that can result in
headache, such as an aneurysm
or giant cell arteritis, are so seri-
ous that delayed diagnosis or
treatment could cause death or
permanent impairment (see the 1. Michel P, Dartigues JF,
Henry P, et al. Validity of
Box: Symptoms Suggesting Se- the International Head-
rious Secondary Causes of ache Society criteria for
migraine. GRIM. Groupe
Headache). de Recherche Interdisci-
plinaire sur la Migraine.
Atypical aspects of the history, Neuroepidemiology.
1993;12:51-7. [PMID:
even in a patient with a history of 8327023]
In the Clinic ITC51 姝 2017 American College of Physicians
 Table 1. Differential Diagnosis of Serious Secondary Causes of Headache
Disease
Subarachnoid
hemorrhage
Acute or chronic subdural
hematoma
Meningitis
Encephalitis
Intracranial neoplasia
Idiopathic intracranial
hypertension
Giant cell arteritis
Acute severe hypertension
Carbon monoxide
poisoning
Acute glaucoma
Carotid dissection
2. Buttgereit F, Dejaco C,
Matteson EL, Dasgupta B.
Polymyalgia rheumatica
and giant cell arteritis: a
systematic review. JAMA.
2016;315:2442-58.
[PMID: 27299619]
3. Huston KA, Hunder GG,
Lie JT, et al. Temporal
arteritis: a 25-year epide-
miologic, clinical, and
pathologic study. Ann
Intern Med. 1978;88:
162-7. [PMID: 626444]
姝 2017 American College of Physicians
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Characteristics
Sudden, explosive onset of severe headache ("worst headache of my life"); sometimes
preceded by "sentinel" headaches (10%)
History of antecedent trauma; may have subacute onset; may have altered level of
consciousness or neurologic deficit
Usually associated with fever and meningeal signs
Associated with neurologic abnormalities, confusion, altered mental state, or change in level
of consciousness
Worse on awakening, generally progressive; headache aggravated by coughing, straining,
or changing position
Often abrupt onset, associated with nausea, vomiting, dizziness, blurred vision, papilledema;
neurologic examination normal but may have cranial nerve VI palsy; headache aggravated
by coughing, straining, or changing position
Patients aged >50 y; associated with tenderness of scalp, the temporal artery, and jaw
claudication; visual changes
Marked blood pressure elevation (systolic ≥210 mm Hg or diastolic ≥120 mm Hg); may have
symptoms of encephalopathy (e.g., confusion, irritability)
May be insidious or associated with dyspnea, if severe; occurs more commonly in the colder
months
Associated with blurred vision and seeing halos around lights
Cause of stroke; can present with headache, can be spontaneous or follow minor trauma or
sudden neck movement; presents as unilateral headache/face pain, ipsilateral Horner
syndrome
migraine, should alert the physi-
cian to the need to exclude a sec- Signs Suggesting Serious
ondary cause of the headache. Secondary Causes of
Onset of migraine after age 50 Headache
years is unusual and is associated Any focal abnormality on
neurologic examination
with an increased likelihood of
Diastolic blood pressure >120
secondary causes. The combina- mm Hg
tion of new-onset headache; jaw, Diminished or absent temporal
tongue, or limb claudication; and artery pulsations
abnormal (nodular or tender) ar- Fever
teries is highly predictive of giant Necrotic lesions of scalp or
cell arteritis. Erythrocyte sedimen- tongue
tation rate or C-reactive protein Nuchal rigidity or limitation of
level is elevated in more than 95% anterior neck flexion
of cases, after which urgent biopsy Papilledema
of the temporal artery is indicated Reddened, tender scalp nodules
(2). Tender or nodular temporal
arteries
A cohort study of patients with giant cell arteritis Decreased visual acuity and
found that headache was the predominant symp- elevated intraocular pressure
tom in 65%– 80% of patients (3).
What is the role of physical
the findings are “normal.” Fewer
examination in patients who
than 1% of patients seen in a spe-
present with migraine?
cialist clinic have headache sec-
The main purpose of a physical ondary to intracranial disease,
examination is to assure both and all of such patients have
physician and patient that no un- signs attributable to the intra-
derlying sinister pathology is cranial process.
causing the headache (see the
Box: Signs Suggesting Serious The examination can be brief but
Secondary Causes of Headache), should be thorough. Particular
and patients can be reassured if attention should be paid to the
ITC52 In the Clinic Annals of Internal Medicine 4 April 2017
 cranial nerves, tendon reflexes,
and optic discs. Pulse and blood
pressure should be measured,
and auscultation for cardiac ab-
normalities and bruits should be
done first and is particularly im-
portant if vasoconstrictor drugs,
such as ergotamine or triptans,
are being considered. Examining
the jaw can identify temporo-
mandibular joint dysfunction that
causes headache. Examination of
the neck and cervical spine may
reveal muscle contraction, cervi-
cal spondylosis, or even
meningismus.
What is the role of diagnostic
testing, including imaging studies
and electroencephalography, in
patients with suspected migraine?
Neuroimaging is not usually war-
ranted for migraine and is un-
likely to reveal an abnormality in
patients with a normal neurologic
examination.
A meta-analysis of studies of patients with mi-
graine and a normal neurologic examination
found significant intracranial lesions at a rate
of 0.18% (4).
A lower threshold for obtaining
neuroimaging should be ap-
plied to patients with unex-
plained abnormal findings on
the neurologic examination or
who have atypical headache
features, particularly headache
worsened by the Valsalva ma-
neuver, headache causing
awakening from sleep, new
headache in an older person, or
progressively worsening head-
ache. These symptoms indicate
a greater likelihood of signifi-
cant intracranial pathology
(5).
Electroencephalography is not
useful for routine evaluation of
patients with headache and
should be considered only if
symptoms suggest a seizure dis-
order, such as atypical migrain-
ous aura or episodic loss of con-
sciousness (6).
Erythrocyte sedimentation rate or
C-reactive protein level should be
measured in patients older than 50
years with new-onset headache.
Elevation is highly sensitive for gi-
ant cell arteritis but lacks specific-
ity; a temporal artery biopsy con-
firms the diagnosis.
When should a neurologist be
consulted?
Migraine and medication-overuse
headache (MOH) can be managed
in primary care. Referral is indi-
cated if the headache is atypical,
remains difficult to classify, or fails
to respond to recommended man-
agement strategies (see the Box:
Reasons for Neurologic Referral).
Are there special considerations
for pregnant women with
symptoms consistent with
migraine?
Migraine is a risk factor for hyper-
tensive disorders of pregnancy
(7). Hence, it is important to con-
sult with an obstetrician to ex-
clude preeclampsia when a preg-
nant woman has headache
associated with peripheral
edema or hypertension.
In pregnant women with a history
of typical migraine features and a
normal neurologic examination,
imaging studies should be de-
ferred until after delivery. When
neuroimaging is needed for ab-
normal findings on neurologic
examination, progressively wors-
ening headache, or an unex-
plained change in headache
pattern, magnetic resonance im-
aging is the study of choice for
most pregnant women.
Head computed tomography is
relatively safe during pregnancy
(exposure <0.05 rad to the fe-
tus) and is the study of choice
for head trauma and suspected
intracranial hemorrhage (8). Re-
ducing the voltage and limiting
the z-axis are more effective
than shields at reducing fetal
dose.
Reasons for Neurologic
Referral
Diagnostic uncertainty
Suspicion of serious secondary
headache
Any headache that is new or
unexpected in an individual
patient, especially:
• In a prepubertal child
• In a patient older than 50 y
• Thunderclap headache
(intense headache with
abrupt or “explosive” onset)
• In a patient with a history of
cancer
• In a patient with HIV
infection or immuno-
deficiency
Unusual migraine aura, especially:
• Duration > 1 h
• Motor weakness
Aura without headache in the
absence of a history of
migraine with aura
Progressively worsening
headache over weeks or
longer
Headache associated with:
• Postural change indicative of
high or low intracranial
pressure
• Unexplained fever
• Unexplained physical signs
• Persistent management
failure
4. Frishberg BM. The utility
of neuroimaging in the
evaluation of headache in
patients with normal neu-
rologic examinations.
Neurology. 1994;44:
1191-7. [PMID: 8035914]
5. Frishberg BM, Rosenberg
JH, Matchar DB, et al.
Evidence-based guidelines
for migraine headache:
neuroimaging in patients
with nonacute headache.
U.S. Headache Consor-
tium; 2000. Accessed at
www.aan.com on 15 Feb-
ruary 2017.
6. Gronseth GS, Greenberg
MK. The utility of the
electroencephalogram in
the evaluation of patients
presenting with headache:
a review of the literature.
Neurology. 1995;45:
1263-7. [PMID: 7617180]
7. Facchinetti F, Allais G,
Nappi RE, et al. Migraine
is a risk factor for hyper-
tensive disorders in preg-
nancy: a prospective co-
hort study. Cephalalgia.
2009;29:286-92. [PMID:
19220309]

4 April 2017 Annals of Internal Medicine In the Clinic ITC53 姝 2017 American College of Physicians

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 Contrast agents should not be have been shown, gadolinium
used unless absolutely necessary. crosses the placental barrier and is
Although no ill effects to the fetus excreted by the fetal kidney.

Diagnosis... Migraine without aura is the most likely headache diagno-

sis in a patient who has had at least 5 episodes of headache lasting
4 –72 hours that are associated with photophobia and phonophobia,
nausea, and disability who is otherwise well between attacks. Aura is
diagnosed when fully reversible symptoms of visual, sensory, motor, or
language abnormalities develop over a minimum of 5 minutes and last
a maximum of 60 minutes; these symptoms resolve before headache
onset. Tension-type headache is a bilateral headache without associ-
ated nausea or disability, lasting 30 minutes to 7 days. Secondary head-
ache must be excluded if focal neurologic signs are present on exami-
nation. Neuroimaging is not warranted in patients with a normal
neurologic examination and typical headache characteristics.

CLINICAL BOTTOM LINE

Treatment
8. American College of Ob-
stetricians and Gynecolo-
gists. ACOG Committee
Opinion No. 299. Obstet
Gynecol. 2004;104:647-
51. [PMID: 15339791]
9. Peatfield RC. Relation-
ships between food, wine,
and beer-precipitated
migrainous headaches.
Headache. 1995;35:
355-7. [PMID:7635722]
10. Van den Bergh V, Amery
WK, Waelkens J. Trigger
factors in migraine: a
study conducted by the
Belgian Migraine Soci-
ety. Headache. 1987;27:
191-6. [PMID: 3597073]
11. Egger J, Carter CM, Wil-
son J, et al. Is migraine
food allergy? A double-
blind controlled trial of
oligoantigenic diet treat-
ment. Lancet. 1983;2:
865-9. [PMID: 6137694]
12. Mansfield LE, Vaughan
TR, Waller SF, et al. Food
allergy and adult mi-
graine: double-blind and
mediator confirmation of
an allergic etiology. Ann
Allergy. 1985;55:126-9.
[PMID: 4025956]
What is the role of diet in
managing patients with
migraine?
The most important dietary trig-
gers for migraine are delayed or
missed meals, so regular meal
times are important; however,
some patients have specific di-
etary “triggers” (9, 10). A few
careful studies have found a
causal relationship between food
and migraine in some children
(11) and adults (12). Patients
should be encouraged to identify
and avoid dietary factors, which
can decrease migraine symptoms
substantially in some, but not all,
individuals. The most commonly
reported dietary triggers are caf-
feine, artificial sweeteners, and
additives (such as monosodium
glutamate). However, it is impor-
tant to note that triggers are highly
individual, so specific triggers
must be identified for each patient.
Suspect foods should be avoided
for at least 4 weeks. If improve-
ment is noted, each food can be
slowly reintroduced to determine
the relevant triggers, bearing in
mind that migraine starts around
24 – 48 hours before the onset of
headache.
Indications for Behavioral
Therapy for Migraine
Preference for nondrug
interventions
Poor tolerance of specific drug
treatments
Medical contraindications for
specific drug treatments
Insufficient or no response to
drug treatment
Pregnancy, planned pregnancy,
or breastfeeding
History of long-term, frequent, or
excessive use of analgesic or
short-term medications (can
aggravate headache
problems or lead to
decreased responsiveness to
other drug therapies)
Significant stress or deficient
stress-coping skills
Is behavioral therapy effective?
Behavioral approaches provide
relief without the adverse effects
associated with drug treatment
(see the Box: Indications for Be-
havioral Therapy for Migraine).
Relaxation training, thermal biofeedback com-
bined with relaxation training, electromyogra-
phy biofeedback, and cognitive behavioral
therapy have been shown in randomized, con-

姝 2017 American College of Physicians ITC54 In the Clinic Annals of Internal Medicine 4 April 2017

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 Figure. Migraine treatment.

Migraine Attack

Requiring an antiemetic or parenteral treatment?

Yes Yes No No

Moderate to Mild to Mild to Moderate to

severe? moderate? moderate? severe?

Antiemetic PO, PR NSAIDs,

NSAIDs, analgesics, analgesics, or
or combination combination
analgesics analgesics

Effective clinical Effective clinical

response?
No
Nonoral medication
DHE SC/IN/PI
Ergotamine/caffeine PR
Prochlorperazine PR
Sumatriptan SC/IN
Zolmitriptan IN
No
Effective clinical
response?
DHE = dihydroergotamine; IM = intramuscular; IN = intranasal; IV = intravenous; NSAID =
nonsteroidal anti-inflammatory drug; PI = pulmonary inhaler; PO = oral; PR = rectal; SC =
subcutaneous.
trolled trials (RCTs) to reduce migraine fre-
quency by 30%–50% (13).
Which drugs are indicated for
patients with mild to moderate
migraine?
For patients with mild to moder-
ate migraine (able to perform
daily activities but function is im-
paired), mild analgesics are pre-
ferred because they are effective,
less costly, and less likely to
cause adverse effects than
migraine-specific drugs. Evi-
dence from well-designed
placebo-controlled trials sup-
ports the use of acetaminophen
(14), aspirin (15), or combined
analgesics (e.g., aspirin plus acet-
aminophen plus caffeine) (16) in
patients with mild to moderate
migraine and no vomiting or se-
response?
Yes Yes No
FOLLOW Triptan, antiemetic, or
combination agent
13. Holroyd KA, Penzien DB.
Almotriptan
Yes Yes Pharmacological versus
Eletriptan non-pharmacological
Frovatriptan prophylaxis of recurrent
Effective clinical Naratriptan migraine headache: a
response? Rizatriptan meta-analytic review of
Sumatriptan clinical trials. Pain. 1990;
Sumatriptan–naproxen 42:1-13. [PMID:
DHE plus prochlorperazine IM 2146583]
Zolmitriptan
Ketorolac IM 14. Derry S, Moore RA.
Paracetamol (acetamino-
phen) with or without an
Inadequate response? antiemetic for acute
migraine headaches in
adults. Cochrane Data-
Hospital/clinic Effective clinical base of Systematic
No response? Reviews 2013:
CD008040. [PMID:
23633349]
15. Kirthi V, Derry S, Moore
RA. Aspirin with or with-
out an antiemetic for
acute migraine head-
aches in adults. Co-
chrane Database Syst
vere nausea. Nonsteroidal anti- Rev. 2013:CD008041.
[PMID: 23633350]
inflammatory drugs (NSAIDs) are 16. Goldstein J, Hoffman
also effective in adequate doses HD, Armellino JJ, et al.
Treatment of severe,
(Figure and Table 2). disabling migraine at-
tacks in an over-the-
counter population of
A systematic review showed that ibuprofen re- migraine sufferers: re-
lieved pain in 1 of 2 patients and achieved sults from three random-
ized, placebo-controlled
complete pain relief in 1 of 4 patients. A single studies of the combina-
400-mg dose had greater efficacy than a tion of acetaminophen,
aspirin, and caffeine.
200-mg dose (17). Cephalalgia. 1999;19:
684-91. [PMID:
10524663]
Antiemetic drugs relieve nausea, 17. Rabbie R, Derry S, Moore
RA. Ibuprofen with or
which is prominent in some pa- without an antiemetic for
tients with migraine. An oral or acute migraine head-
aches in adults. Co-
rectal antiemetic in patients with chrane Database of Sys-
tematic Reviews. 2013:
mild to moderate nausea can fa- CD008039. [PMID:
cilitate the use of oral analgesics 23633348]
18. Friedman BW, Mulvey L,
for migraine pain relief (15). Esses D, et al. Metoclo-
pramide for acute mi-
graine: a dose-finding
A dose-ranging study found that metoclopra- randomized clinical trial.
Annals of emergency
mide, 10 mg, was as effective for acute mi- medicine. 2011;57:475-
graine as 20- and 40-mg doses (18). 82. [PMID: 21227540]

4 April 2017 Annals of Internal Medicine In the Clinic ITC55 姝 2017 American College of Physicians

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 Table 2. Short-Term Therapies for Migraine
Drug Recommended Dose Maximum Daily Dose
Nonsteroidal anti-inflammatory drugs
Aspirin 600–900 mg 4000 mg
Diclofenac 50–100 mg 200 mg
Ibuprofen 400–800 mg 1200 mg
Naproxen sodium 250–1000 mg 1000 mg
Combination of acetaminophen 2 caplets 2 caplets
250 mg/aspirin 250 mg/caffeine 65 mg

Migraine-specific oral agents

Almotriptan* 6.25–12.5 mg 25 mg
Eletriptan† 20–40 mg 80 mg
Frovatriptan† 2.5 mg 7.5 mg
Naratriptan† 1–2.5 mg 5 mg
Rizatriptan† 5–10 mg 20 mg
Sumatriptan* 25–100 mg 300 mg
Sumatriptan 85 mg–naproxen 500 mg 1 tablet 2 tablets
Zolmitriptan† 2.5–5 mg 10 mg

Nonoral therapies
Dihydroergotamine 1 mg nasally, repeated in 15 min if needed 2 mg
1 mg subcutaneously, repeated in 30–60 3 mg
min if needed
Prochlorperazine 10 mg intravenously (5 mg/min) 40 mg
25 mg rectally 50 mg
Promethazine 12.5–25 mg intravenously 100 mg
25 mg rectally 100 mg
Sumatriptan† 5–20 mg nasally 40 mg
22 mg breath-powered delivery 44 mg
4–6 mg subcutaneously, repeated in no 12 mg
less than 60 min if needed
Zolmitriptan* 5 mg nasally 10 mg

* May repeat dose ≥2 h after the first dose if needed.

† May repeat dose if symptoms recur ≥2 h (≥4 h for naratriptan) after initial response.

Which drugs are indicated for more effective than ergots and
19. Lipton RB, Stewart WF, patients with severe migraine? cause less nausea. Meta-analyses
Stone AM, et al. Strati-
fied care vs step care Patients with severe migraine are of RCTs show the efficacy of sub-
strategies for migraine:
unable to perform daily activities cutaneous, oral, and nasal su-
the Disability in Strate-
gies of Care (DISC) and are often confined to bed. matriptan (20) and the 6 later oral
Study: A randomized
trial. JAMA. 2000;284: Failure to use an effective treat- triptans: naratriptan, zolmitriptan,
2599-605. [PMID:
ment promptly may increase pain rizatriptan, eletriptan, almotriptan,
11086366]
20. Derry CJ, Derry S, Moore and disability, so migraine-specific and frovatriptan (21, 22).
RA. Sumatriptan (all
routes of administration) agents (e.g., triptans or dihydroer-
for acute migraine at- gotamine) are indicated. Oral formulations are appropri-
tacks in adults— overview
of Cochrane reviews. ate when nausea is mild to mod-
Cochrane Database of An RCT showed that for patients with severe at- erate and vomiting is absent at
Systematic Reviews
2014: CD009108. tacks, initially selecting a migraine-specific drug the time of treatment. Because
[PMID:24865446] led to better outcomes than a stepped-care ap- comparative studies do not
21. Ferrari MD, Roon KI,
Lipton RB, et al. Oral proach in which patients first used a simple anal-
clearly establish superiority of
triptans (serotonin gesic and then progressed to migraine-specific
5-HT(1B/1D) agonists) in one oral triptan over another, the
acute migraine treat- agents only if initial treatment failed (19).
ment: a meta-analysis of choice of a specific agent may be
53 trials. Lancet. 2001;
358:1668-75. [PMID:
Triptans are a first-line migraine- made on the basis of formulary
11728541] specific agent because they are availability and previous thera-

姝 2017 American College of Physicians ITC56 In the Clinic Annals of Internal Medicine 4 April 2017

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 peutic trials. Sumatriptan is the No evidence supports the effi-
only triptan that can be adminis- cacy of butalbital compounds,
tered subcutaneously and is the despite their widespread use.
fastest-acting and most effica-
cious. It is indicated for migraine A nonoral route of administration
is usually necessary in patients
accompanied by severe nausea
with moderate to severe nausea
or vomiting, for migraine already
or vomiting.
established by the time of awak-
ening, and in patients who do A 2009 meta-analysis found that phenothia-
not respond consistently to oral zines, such as prochlorperazine, relieve mi-
or nasal preparations. An oral graine as well as nausea and were more effec- 22. Oldman AD, Smith LA,
combination of sumatriptan and tive than placebo for migraine treatment. McQuay HJ, et al. Phar-
Phenothiazines were more effective than other macological treatments
naproxen is also available, and for acute migraine:
this formulation has been shown antiemetic drug groups, including metoclopra- quantitative systematic
mide (28). review. Pain. 2002;97:
to provide more effective mi- 247-57. [PMID:
12044621]
graine relief than either drug What is the appropriate 23. Khoury CK, Couch JR.
alone (23). Sumatriptan-naproxen
strategy for patients who do fixed combination for
not respond to their usual acute treatment of mi-
Triptans are contraindicated in graine: a critical ap-
first-line treatment? praisal. Drug Des Devel
patients with known or suspected Ther 2010;4:9-17.
For refractory headache that fails
vasospastic or ischemic vascular [PMID: 20368903]
to respond to usual treatment, 24. Tepper SJ. Serotonin
disorders, uncontrolled hyper- syndrome: SSRIs, SNRIs,
pain relief—rather than preserving triptans, and current
tension, and the rare migraine clinical practice. Head-
the ability to function— becomes
subtypes hemiplegic migraine ache: The Journal of
the overriding objective. Despite Head and Face Pain.
(headache accompanied by mo- 2012;52:195–197.
widespread use, opiate analgesics [PMID: 22221260]
tor weakness) or migraine with
in oral (e.g., codeine-, 25. Winner P, Ricalde O, Le
brainstem aura (aura includes Force B, et al. A double-
hydrocodone-, or oxycodone- blind study of subcutane-
such symptoms as dysarthria, ous dihydroergotamine
containing compounds) or nasal vs subcutaneous su-
ataxia, vertigo, tinnitus, or de-
(butorphanol) formulations have matriptan in the treat-
creased consciousness). Adverse ment of acute migraine.
limited evidence of efficacy and Arch Neurol. 1996;53:
effects include limb heaviness; should be used only as a last resort 180-4. [PMID: 8639069]
flushing; paresthesias; and tight- (29).
26. Colman I, Brown MD,
Innes GD, et al. Paren-
ness in the chest, neck, or throat. teral dihydroergotamine
for acute migraine head-
These side effects are almost al- If simple or combination analge- ache: a systematic review
ways benign and can be mitigated sics have been used as first-line of the literature. Ann
Emerg Med. 2005;45:
by reducing the dose, switching to treatment, a triptan with or with- 393-401. [PMID:
15795718]
an alternative triptan, or treating out an antiemetic is appropriate. 27. Tfelt-Hansen P, Saxena
earlier in the attack. Although se- If an oral triptan has been used, PR, Dahlof C, et al. Ergot-
amine in the acute treat-
vere cardiovascular reactions have nonoral preparations of triptans, ment of migraine: a
been associated with triptans, the ergots, or phenothiazines can be review and European
consensus. Brain. 2000;
incidence is estimated at fewer tried (Figure). Dihydroergota- 123:9-18. [PMID:
10611116]
than 1 event per 4 million treat- mine together with prochlorpera- 28. Kelly AM, Walcynski T,
ments. Drug interactions are rare, zine given by intramuscular injec- Gunn B. The relative
efficacy of phenothia-
and evidence suggests that com- tion can be used when other zines for the treatment of
bining these drugs with antide- nonoral strategies have failed. acute migraine: a meta-
analysis. Headache.
pressants does not significantly Intramuscular ketorolac, an 2009;49:1324-32.
[PMID: 19496829]
increase risk for serotonin syn- NSAID, is an alternative. 29. Langer-Gould AM, Ander-
son WE, Armstrong MJ,
drome (24). A 2013 systematic review found that ketorolac et al. The American Acad-
emy of Neurology's top
Nonoral dihydroergotamine can was more effective than intranasal sumatriptan five Choosing Wisely
and showed efficacy similar to that of phe- recommendations. Neu-
be an effective alternative to su- rology. 2013;81: 1004.
nothiazines (30). [PMID: 23430685]
matriptan (25, 26), but the effec- 30. Tagart E, Doran S, Koko-
tiveness of ergotamine is less Hospitalization for parenteral tillo A, et al. Ketorolac in
the treatment of acute
certain (27). Ergots are also con- treatment should be considered migraine: a systematic
traindicated in the presence of if there is no effective clinical review. Headache. 2013;
53: 277-87. [PMID:
coronary artery disease. response. 23298250]

4 April 2017 Annals of Internal Medicine In the Clinic ITC57 姝 2017 American College of Physicians

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 When should clinicians consider
Preventive Migraine Therapies preventive therapy, and which
Available in the United States drugs should be used?
Level A: Medications with established Pharmacologic prophylaxis of mi-
efficacy (≥two phase 1 trials) graine is indicated in the following
Antiepileptic drugs situations: recurrent headache that
Divalproex sodium interferes with daily routine; con-
traindications to, failure of, or over-
Sodium valproate
use of short-term therapy (e.g.,
Topiramate
when it is often required >2 days
␤-blockers per week); adverse effects from
Metoprolol short-term therapy; patient prefer-
Propranolol ence; or uncommon types of mi-
Timolol graine (e.g., hemiplegic migraine
or migraine with brainstem aura).
Triptans (menstrually related
migraine) Daily preventive drug treatment
Frovatriptan should be considered in patients
with significant disability related to
Level B: Medications that are probably
effective (one phase 1 or two phase 2 frequent or severe migraine at-
studies) tacks (usually ≥2 per month) and in
Antidepressants patients for whom short-term med-
ications do not effectively control
Amitriptyline
the attacks, are contraindicated, or
Venlafaxine are overused. If attacks are fre-
␤-blockers quent enough, the expected 33%–
Atenolol 55% reduction warrants the risk,
Nadolol cost, and inconvenience of a daily
preventive medication.
Triptans (menstrually related
migraine) The U.S. Headache Consortium
Naratriptan guidelines for preventive therapy
of migraine identify 3 goals: reduc-
Zolmitriptan
ing the frequency, severity, and
Level C: Medications that are possibly duration of attacks; improving the
effective (one phase 2 study)
response to treatment of acute
Angiotensin-converting
attacks; and improving function
enzyme inhibitors: Lisinopril
and reducing disability (31).
␣2-agonists: Guanfacine
Angiotensin-receptor Avoiding the use of acute head-
blockers: Candesartan ache medications, analgesics, de-
congestants, and stimulants for
Antiepileptic drugs:
Carbamazepine
more than 10 days per month is
critical for ensuring optimal benefit
Antihistamines:
from the prophylactic drug. In pa-
Cyproheptadine
tients who overuse short-term
␤-blockers: Nebivolol medications, such as butalbital
Calcium-channel blockers: and opiate compounds, gradual
Nicardipine tapering over several weeks may
be necessary, and a full response
to preventive therapies may be
delayed by several months.
Drug selection should be based
first on efficacy, with consideration
given to patient preference and
adherence. Comorbid conditions
姝 2017 American College of Physicians ITC58 In the Clinic
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and the drug's side effect profile
must be taken into account when a
preventive drug is being chosen.
All migraine-preventive drugs
have primary indications for other
conditions, some of which are rela-
tively common in persons with mi-
graine, including stroke, myocar-
dial infarction, Raynaud
phenomenon, epilepsy, affective
disorders, and anxiety disorders.
Evidence for episodic migraine
prevention is strongest for pro-
pranolol (60 –240 mg/d), timolol
(5–30 mg/d), divalproex sodium
(500 –2000 mg/d), and topiramate
(100 –200 mg/d) (32) (see the Box:
Preventive Migraine Therapies
Available in the United States).
Prophylactic agents are generally
titrated upward for a few weeks
and then maintained for 4 – 8
weeks before benefit is realized.
Adherence can be enhanced with
the use of daily or twice-daily dos-
ing. Menstrually related migraine
can be prevented by perimen-
strual (2 days before, continuing
for 6 days) use of frovatriptan, 2.5
mg twice daily (33). Behavioral
therapy (e.g., relaxation, biofeed-
back) can be combined with pre-
ventive drug therapy for additional
clinical improvement. Several com-
plementary treatments, including
Petasites (butterbur), Feverfew,
high-dose riboflavin (vitamin B2),
and magnesium, have shown effi-
cacy in clinical trials and should be
considered for migraine preven-
tion (34).
What is MOH, and how can it
be prevented and treated?
Although correct use of pre-
scribed and over-the-counter
medications can alleviate head-
ache, regular overuse can have a
paradoxical effect, causing rather
than relieving headache and
leading to MOH. Dose frequency
is more important than the abso-
lute quantity of drug consumed—
lower daily doses carry greater
risk for MOH than larger episodic
Annals of Internal Medicine 4 April 2017
 doses. MOH should be sus-
pected in patients who have
headache 15 or more days per
month and have taken ergots,
triptans, opioids, combined anal-
gesic medications, or any combi-
nation of these drugs on 10 or
more days per month, or simple
analgesics on 15 or more days
per month for more than 3
months. The type of headache
restrictions not to exceed a fre- 31. Morey SS. Guidelines on
migraine: part 4. General
quency of more than 2 days per principles of preventive
week. Patients should be fol- therapy. Am Fam Physi-
cian. 2000;62:2359-60,
lowed regularly to prevent re- 2363. [PMID:
11126860]
lapse, which is most likely in the 32. Fraass BA, Lichter AS,
first year after withdrawal. McShan DL, Yanke BR,
Diaz RF, Yeakel KS, et al.
The influence of lung
When should clinicians density corrections on
treatment planning for
consider hospitalization? primary breast cancer. Int
Hospitalization should be consid- J Radiat Oncol Biol Phys.
1988;14:179-90. [PMID:
ered for a particularly severe, in- 3335452]

may be tension-type daily head- tractable migraine attack lasting 33. Silberstein SD, Elkind
AH, Schreiber C, Key-
ache or migraine-like attacks. As- longer than 72 hours (status mi- wood C. A randomized
trial of frovatriptan for
sociated symptoms can include grainosus) or headache associ- the intermittent preven-
nausea and other gastrointestinal ated with excessive use of anal- tion of menstrual mi-
graine. Neurology. 2004;
disorders, irritability, anxiety, de- gesic medications (MOH). 63: 261-9. [PMID:
15277618]
pression, and difficulty with con- Intravenous prochlorperazine or 34. Holland S, Silberstein
SD, Freitag F, et al.
centration and memory. MOH metoclopramide, which can be Evidence-based guide-
usually, but not invariably, re- combined with intravenous di- line update: NSAIDs and
other complementary
solves after overuse is stopped. phenhydramine (to limit or elimi- treatments for episodic
migraine prevention in
Prevention is preferred to man- nate possible dystonic reactions) adults: report of the
Quality Standards Sub-
agement and includes restricting and hydration, is the most effec- committee of the Ameri-
commonly implicated medica- tive treatment in the emergency can Academy of Neurol-
ogy and the American
tions and avoiding caffeine and setting and has the highest level Headache Society. Neu-

codeine. Early medical or behav- of evidence (37). Intravenous ke- rology. 2012;78:1346-
53. [PMID: 3335449]
ioral prophylaxis may be appro- torolac is also useful, and the ad- 35. Dodick DW, Turkel CC,
DeGryse RE et al. On-
priate in patients with frequent dition of a single dose of dexa- abotulinumtoxinA for
headache. Patients with primary methasone seems to reduce treatment of chronic
migraine: pooled results
headache should be educated recurrence (38). from the double-blind,
randomized, placebo-
about the risk for medication Are there special considerations controlled phases of the
overuse and be encouraged to PREEMPT clinical pro-
for pregnant patients? gram. Headache. 2010;
keep a diary to monitor head- Migraine can develop or worsen 50:921-36. [PMID:
20487038]
ache frequency and drug use. during the first trimester of preg- 36. Diener HC, Bussone G,
Van Oene JC et al. Topi-
Once MOH has developed, man- nancy. However, approximately ramate reduces head-
two thirds of women with mi- ache days in chronic
agement involves educating the migraine: a randomized,
patient on the cause, as well as graine have improvement or re- double-blind, placebo-
controlled study. Cepha-
drug withdrawal. Overall im- mission of attacks during the last lalgia. 2007;27:814-23.
provement occurs within 7–10 6 months of pregnancy (39); this [PMID:17441971]
37. Orr SL, Aube M, Becker
days when the causative drug is a is believed to result from the sus- WJ, et al. Canadian
tained estrogen levels in the sec- Headache Society sys-
triptan, after 2–3 weeks when it is tematic review and rec-
a simple analgesic, and after 2– 4 ond and third trimesters. ommendations on the
treatment of migraine
weeks when it is an opioid. For most women, migraine in
pain in emergency set-
tings. Cephalalgia. 2015;
Follow-up should occur after 2–3 pregnancy is usually benign and 35:271-84. [PMID:
weeks to ensure withdrawal has there is no significant effect on
24875925]
38. Colman I, Friedman BW,
been achieved. Recovery contin- the mother or fetus. However, Brown MD, et al. Paren-
teral dexamethasone for
ues slowly for weeks to months, recent population-based studies acute severe migraine
and follow-up is necessary. Most have documented an association
headache: meta-analysis
of randomised controlled
patients revert to their original between migraine, pregnancy- trials for preventing
headache type within 2 months. recurrence. BMJ. 2008;
induced hypertension, and pre- 336:1359-61. [PMID
OnabotulinumtoxinA (35) or topi- eclampsia. This risk is highest in 18541610]
39. Granella F, Sances G,
ramate (36) may help reduce women older than 30 years and Zanferrari C, et al. Mi-
withdrawal symptoms. The over- those who are obese (40).
graine without aura and
reproductive life events:
used medications can be reintro- a clinical epidemiological
duced if needed for symptomatic Nonpharmacologic therapies, in- study in 1300 women.
Headache. 1993;33:
relief after 2 months, with explicit cluding magnesium supplementa- 385-9. [PMID: 8376100]

4 April 2017 Annals of Internal Medicine In the Clinic ITC59 姝 2017 American College of Physicians

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40. Adeney KL, Williams MA,
Miller RS, et al. Risk of
preeclampsia in relation
to maternal history of
migraine headaches. J
Matern Fetal Neonatal
Med. 2005;18:167-72.
[PMID: 16272039]
41. Scharff L, Marcus DA,
Turk DC. Maintenance of
effects in the nonmedical
treatment of headaches
during pregnancy. Head-
ache. 1996;36:285-90.
[PMID: 8682668]
42. Ephross SA, Sinclair SM.
Final results from the
16-year sumatriptan,
naratriptan, and Treximet
pregnancy registry.
Headache. 2014;54:
1158-72. [PMID:
24805878]
43. Olesen C, Steffensen FH,
Sorensen HT, et al. Preg-
nancy outcome following
prescription for su-
matriptan. Headache.
2000;40:20-4. [PMID:
10759898]
44. Sachs HC, Committee on
D. The transfer of drugs
and therapeutics into
human breast milk: an
update on selected top-
ics. Pediatrics. 2013;132:
e796-809. [PMID:
23979084]
姝 2017 American College of Physicians
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tion and simple remedies (such as fits outweigh the risks: A 16-year
rest and local application of ice), prospective sumatriptan preg-
are strongly preferred for migraine nancy registry produced no evi-
prevention during pregnancy and dence of significant teratogenic-
for attacks persisting throughout ity (42), although some studies
pregnancy. found an increased rate of low
birthweight and preterm delivery
In a prospective study, 30 pregnant women were
(43). Ergots are potent vasocon-
treated with physical therapy, relaxation training,
and biofeedback. Headache was significantly re- strictors and may induce abortion
lieved after treatment in 80%, and this beneficial and cause birth defects.
effect was maintained for up to a year after deliv-
ery (41).
Prophylactic medication should
be limited to women with partic-
All short-term and preventive mi- ularly frequent or disabling mi-
graine therapies have U.S. Food graine attacks. ␤-Blockers are
and Drug Administration and rated Category C (except
Teratogen Information System atenolol, which is Category D)
pregnancy ratings. For short- but have demonstrated relative
term treatment, acetaminophen safety during pregnancy. They
and metoclopramide; caffeine; should be tapered during the last
and the NSAIDs diclofenac, ibu- weeks of pregnancy to avoid ma-
profen, and naproxen are classi- ternal or fetal bradycardia during
fied as Pregnancy Category B (no labor. Treatment should be
evidence of risk in humans but started at the lowest effective
no controlled human studies). dose, and response and adverse
NSAIDs have been linked with events should be monitored.
fetal patent ductus arteriosus
when used later in pregnancy The American Academy of Pedi-
and should be discontinued be- atrics provides additional safety
fore week 32. Although meperi- information for lactating mothers
dine is also classified as Preg- (44). NSAIDs, with the exception
nancy Category B (the same as of aspirin, can be used during
for nonpregnant women), opi- lactation. Sumatriptan should be
oids are not recommended, and used if triptans are indicated. Er-
use late in the third trimester gots are contraindicated. If pro-
risks neonatal withdrawal. Predni- phylaxis is necessary, proprano-
sone carries a Category B rating lol and amitriptyline can be used
and may be useful in truncating during lactation. Breastfeeding is
stretches of active migraine. encouraged for women whose
Triptans are rated Category C headache improves during preg-
(risk to humans not ruled out) nancy because it sustains the
and can be used when the bene- benefits of pregnancy.
Treatment... Patients should be encouraged to identify and avoid diet-
related factors. Behavioral approaches provide headache relief without
the adverse effects associated with drug treatment. Simple or com-
pound analgesics are suitable for mild to moderate migraine. Triptans
and ergots should be used in patients with severe migraine. Opiate an-
algesics have limited use as rescue medications and should only be
used as a last resort. Antiemetics provide symptomatic relief of nausea
and can facilitate the use of oral analgesics for migraine pain relief. Pro-
pranolol, timolol, divalproex sodium, and topiramate have the strongest
evidence of effectiveness in preventing episodic migraine.
CLINICAL BOTTOM LINE
ITC60 In the Clinic Annals of Internal Medicine 4 April 2017

What are the components of
good follow-up care?
Patients should generally be re-
evaluated after treatment of at
least 3 attacks. Patients should
keep a headache diary to record
severity, associated disability,
and treatment response. These
diaries and the need for preven-
tive treatment should be re-
viewed at follow-up. Preventive
therapy is indicated if there is
poor response to treatment or a
frequent need for rescue medica-
tion, which puts the patient at risk
for MOH. Increasing dose or
changing agents should be con-
sidered if headache frequency is
not reduced after 3 months of
preventive treatment.
Is it appropriate to taper or
discontinue preventive
treatment?
Most clinicians recommend a
6- to 12-month maintenance
phase after a response (often
defined as a 50% reduction in
headache frequency) has been
achieved, followed by a taper-
ing phase with the aim of dis-
continuation if there is no re-
lapse. As migraine symptoms
change over time and preven-
tive treatment may no longer be
needed, this may avoid the risks
and costs associated with un-
necessary drug therapy.
Follow-up... Symptomatic treatment should be reviewed after at least 3
attacks and prophylactic treatment after 3 months. The patient should
keep a headache diary to assess treatment response. Subspecialty re-
ferral may be indicated under certain circumstances.
4 April 2017 Annals of Internal Medicine
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Follow-up
When should clinicians
consider subspecialty referral?
A neurologist or headache spe-
cialist should be consulted to de-
termine an appropriate further
diagnostic work-up in patients
with possible ophthalmic, basilar,
atypical, or complicated migraine
(i.e., patients with neurologic def-
icits during the aura phase or that
persist during or after the head-
ache). Patients with status mi-
grainosus or MOH may also ben-
efit from referral. Alternative and
more intensive approaches (e.g.,
multidisciplinary headache clin-
ics) have yielded good outcomes
in uncontrolled case series (45).
A neuroophthalmologist or an
ophthalmologist should be con-
sulted when headache is associ-
ated with visual changes other
than typical aura. A significant
change in visual acuity or fields or
elevated intraocular pressure, es-
pecially with eye-centered pain,
may indicate acute glaucoma,
which must be treated promptly to
preserve vision. New-onset vision
symptoms in persons older than
50 years may indicate giant cell
arteritis. An obstetrician should be
consulted for pregnant women
who have headache associated
with peripheral edema or hyper-
tension (diastolic blood pres-
sure ≥90 mm Hg) because they
may have preeclampsia (7).
CLINICAL BOTTOM LINE
45. Saper JR, Lake AE III,
Madden SF, et al. Com-
prehensive/tertiary care
for headache: a 6-month
outcome study. Head-
ache. 1999;39:249-63.
[PMID: 9747046]
In the Clinic ITC61 姝 2017 American College of Physicians
 Practice Improvement
What should patients be taught
about managing their migraine?
Education about the goals, use,
and the patient's expectations of
migraine preventive therapies is
crucial in maximizing therapeutic
success. The patient must under-
stand that although these thera-
pies may reduce the frequency
or severity of attacks, improve
the efficacy of short-term medica-
tions, and assist in the manage-
ment of comorbidities, they
rarely result in complete head-
ache eradication.
Approximately half of patients
with recurrent headache do not
properly adhere to drug treat-
ment regimens, and as many as
two thirds do not optimize use of
rescue medications. Treatment
can be improved through devel-
opment of a self-management
plan that all parties (e.g., patient,
primary care physician, neurolo-
gist, psychologist) acknowledge
and accept. The plan should
identify treatment methods, in-
cluding those used for coexisting
conditions; limits on dosing and
rescue medication; and how and
when to contact a health care
provider.
In 1 RCT, patients who received an adjunctive
educational intervention used abortive medi-
cation for a greater percentage of migraine at-
tacks (70% vs. 40%) and had greater reduction
in headache (40% vs. 26%) (46).
Patients should be encouraged
to identify and avoid lifestyle-
related factors that may contrib-
ute to headache, including too
little or too much sleep, lack of
exercise, and stress. Modifica-
tions in diet, exercise, and sleep
significantly affect headache re-
sponse and affective distress
(47). Headache diaries help track
headache and related symptoms
between clinic visits. They must be
user-friendly and measure fre-
quency, severity, duration, disabil-
ity, type of treatment, treatment
response, and adverse effects of
medication. Free printable head-
ache diaries are available from the
American Headache Society
(https://americanheadachesociety
.org/patient-education).

46. Holroyd KA, Cordingley

GE, Pingel JD, et al.
Enhancing the effective-
ness of abortive therapy:
a controlled evaluation of
self-management train-
ing. Headache. 1989;29:
148-53. [PMID:
2496052]
47. Hoodin F, Brines BJ,
Lake AE 3rd, et al. Behav-
ioral self-management in
an inpatient headache
treatment unit: increas-
ing adherence and rela-
tionship to changes in
affective distress. Head-
ache. 2000;40:377-83.
[PMID: 10849032]

姝 2017 American College of Physicians ITC62 Annals of Internal Medicine 4 April 2017

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 In the Clinic Patient Information
https://medlineplus.gov/migraine.html

Tool Kit
Information on migraine from the National Institutes of
Health MedlinePlus.
www.acponline.org/system/files/documents/patients
_families/products/facts/migraine.pdf
www.acponline.org/system/files/documents/patients
_families/pdfs/health/migraine.pdf
Patient resources on migraine and its prevention and
Migraine control from the American College of Physicians.
https://americanmigrainefoundation.org/living-with
-migraine/types-of-headachemigraine
Information for patients on migraine from the American
Migraine Foundation.
www.ninds.nih.gov/Disorders/All-Disorders/Migraine
-Information-Page
Information on migraine from the National Institute of
Neurological Disorders and Stroke of the National
Institutes of Health.

IntheClinic
Clinical Guidelines
www.neurology.org/content/55/6/754.full.pdf
Evidence-based guidelines for migraine from the
American Academy of Neurology in 2000.
www.neurology.org/content/78/17/1346.full.pdf+html
www.neurology.org/content/78/17/1337.full.pdf+html
Guideline updates on nonsteroidal anti-inflammatory drugs
for treatment of migraine, as well as complementary and
pharmacologic methods for migraine prevention from the
American Academy of Neurology in 2012.
www.guideline.gov/content.aspx?id=38444
Guidelines on the diagnosis and management of head-
aches in young people and adults from the National
Institute for Health and Clinical Excellence in 2012.
www.aafp.org/afp/2005/0315/p1219.html
Guidelines for neuroimaging in patients with nonacute
headache from the U.S. Headache Consortium in 2005.

Headache Diary
www.headaches.org/wp-content/uploads/2015/02
/248072334-Headache-Diary-from-the-National
-Headache-Foundation.pdf
Diaries help track headache and related symptoms be-
tween clinic visits. They must be user-friendly and mea-
sure attack frequency, severity, duration, triggers, type
of treatment, and treatment response.

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 WHAT YOU SHOULD In the Clinic
Annals of Internal Medicine
KNOW ABOUT MIGRAINE
What Are Migraines?
A migraine is a type of headache that differs from
other headaches by causing severe pain and
other symptoms. These headaches can last from
a few hours to several days and can affect your
day-to-day activities. If your parents have mi-
graine, it is more likely that you will, too.

What Are the Symptoms?

• Throbbing or pounding headache.
• Feeling sensitive to light or sound.
• Nausea and vomiting.
• Some migraines include an aura. An aura can
cause you to see spots, flashes of light, or bright
spots before the headache starts. Sometimes
auras can include a “pins and needles” feeling in
the face or arms and trouble thinking and
speaking.
How Are They Diagnosed?
• Your health care professional will ask you
questions about your family history and
symptoms. The process may also include a
physical examination to check for other causes
of your headaches.
• This is usually all the information your health
care professional needs to diagnose migraine.
• If your exam shows something unusual, you
may need imaging tests, such as magnetic
resonance imaging (MRI) or computed
tomography (CAT scan). However, these tests
and when to take these medicines. Using certain
medicines too often can make migraine worse.
How Can I Manage My Migraine?
Migraine can be caused by “triggers” like certain
foods or stress. Some common triggers include:
• Certain foods. Drinks with caffeine like coffee,
tea, and soda; some artificial sweeteners; and
additives like MSG.
• Sleeping too little or too much.
• Not exercising enough.
• Stress.
Some people choose to keep a migraine diary,
which helps track what caused the migraine,
how long it lasted, how bad it was, and what

are rarely needed.
How Are They Treated?
• Migraine can usually be controlled with
lifestyle changes and medicines to reduce
pain, such as acetaminophen, aspirin, and
nonsteroidal anti-inflammatory drugs.
• Some people take antinausea medicines when
they have a migraine.
• If you have severe migraine, medicines called
triptans might reduce the length and severity.
• If you have frequent migraine, some other
medicines might decrease the frequency.
• Ask your health care professional what medi-
cines are best for you and your migraine
symptoms. It is important to understand how
Patient Information
made it better.
Free printable headache diaries are available from
the American Headache Society: https:
//americanheadachesociety.org/patient
-education
Questions for My Doctor
• How can I find out what triggers my migraine?
• How can I change my lifestyle to help prevent
migraine?
• Are there foods I should avoid?
• What should I do when I feel a migraine
coming on?
• What are the best medicines for my migraine?
Are there side effects?
• Will I get migraine for the rest of my life?

For More Information

American College of Physicians
www.acponline.org/system/files/documents/patients_families
/products/facts/migraine.pdf
MedlinePlus
https://medlineplus.gov/migraine.html
Choosing Wisely
http://consumerhealthchoices.org/headache
http://consumerhealthchoices.org/migraine

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