Mount Carmel Health Partners Clinical Guidelines Migraine | Page 7

TABLE E: Non-Pharmacologic Therapies
Lifestyle Management
Environmental Management
Stress management/relaxation management Biofeedback
Regular exercise and sleep
Routine meal schedule Cryotherapy/thermotherapy
Cognitive behavioral therapy
Limit caffeine
Consume at least 40-80 oz. of non-caffeine fluid daily Avoidance of known triggers
TABLE F: Prophylactic Therapy
Medication
Antihypertensives
• Beta-blockers
(atenolol, metoprolol, nadolol, nebivolol,
propranolol, timolol)
• Calcium channel blockers (verapamil)
• ACE inhibitors/ARBs (lisinopril, candesartan)
Tricyclic antidepressants
(amitriptyline, doxepin, nortriptyline)
Serotonin-norepinephrine reuptake inhibitors (SNRI)
(venlafaxine)
Anticonvulsants
(divalproex sodium, topiramate)
Remarks
Blood pressure treatment appears to reduce the overall prevalence of headache.
Can take several weeks to be effective and should NOT be used as initial therapy for
migraine prophylaxis in patients over age 60 and in smokers.
Contraindicated in patients with uncontrolled asthma, decompensated heart failure,
heart block, severe bradycardia and severe hepatic impairment. Use caution with
patients with depression, impotence, or hypotension.
Tolerance may develop. Verapamil first choice for therapy.
Established role in headache prophylaxis; can lead to hypotension, dizziness, fatigue,
and cough.
Established role in headache prophylaxis. Severe anticholinergic effects and weight
gain can be limiting. May be useful if patient has depression or a sleep issue.
May be useful in patients with co-morbid panic or anxiety disorders
Valproate and topiramate are approved by the US FDA for migraine prophylaxis.
Avoid using in females of childbearing age.
TABLE G: Abortive Therapy
Medication
NSAIDs
Acetaminophen
Triptans: sumatriptan, zolmitriptan,
naratriptan, rizatriptan, almotriptan, frovatriptan
Ergotamine
Dihydroergotamine (DHE 45)
Remarks
Avoid in patients with active gastritis, peptic ulcer disease, renal insufficiency, and
bleeding disorders. Not recommended for chronic daily use.
Can be used in combination with NSAIDs but avoid daily use.
Inhibits the release of vasoactive peptides, promotes vasoconstriction and blocks
pain pathways in the brainstem. Do not use in complex migraine as it increases the
risk of stroke. (Complex migraine is one in which there are
neurologic symptoms, such as weakness, vision loss, and difficulty in speaking, in
addition to headache. It may be mistaken for a stroke.)
May worsen nausea and vomiting. Should be avoided in patients with
coronary artery disease, peripheral vascular disease, hypertension, and hepatic or
renal disease. Should not be used in patients with prolonged aura.
An alpha-adrenergic blocker with fewer side effects than ergotamine. Should not be
used in patients with hypertension or ischemic heart disease, in
combination with MAO inhibitors, or the elderly.
Antiemetic: chlorpromazine
prochlorperazine metoclopramide Use for treatment of symptomatic nausea and vomiting.
Other medications Some patients may require additional analgesics (i.e., fioricet, tramadol).
Benzodiazepines, opioids, and barbiturates are all options, but they should not be
used on a chronic basis since they are habit-forming and can contribute to rebound
and chronic daily headaches.
Migraine - 7