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Migraine management
Bronwyn Jenkins
Neurologist, North Shore SUMMARY
Vertigo and Neurology
Clinic, and Royal North Migraine causes significant lost time from everyday activities. Addressing lifestyle triggers and
Shore Hospital, Sydney comorbidities in patients with migraine is the first step of management.
Acute migraine treatments primarily manage the headache component and should be started as
Keywords early as possible in the migraine attack.
calcitonin gene-related
peptide, migraine, triptans Prophylaxis may be recommended if a patient is having three or more migraines a month or if
their migraines are difficult to manage.
Aust Prescr 2020;43:148–51 The choice of prophylactic drugs should be tailored to the individual’s potential for adverse
https://doi.org/10.18773/ effects, interactions and comorbidities.
austprescr.2020.047

Introduction weight and exercise are recommended. Depending on

Migraine is more than just a headache – it has the individual triggers, behavioural and psychological
associated features including sensitivity to light strategies and physical therapy can help some
or noise, nausea and avoidance of exertion. The patients. Commonly used natural migraine preventives
headache is typically throbbing and severe. As such, include magnesium, riboflavin, coenzyme Q-10, and
migraine is debilitating and is the leading cause of Feverfew. These have limited and variable levels
disability in people under 50 years old.1 of evidence for efficacy and are not the mainstay
of treatment.3,4
Pathophysiology
Pharmacotherapy
Migraine is a common, polygenetic brain disorder
with complex biology. The vascular reactivity of aura Drugs can be used to treat acute migraine, or they can
is now considered to be a secondary symptom that be used prophylactically to reduce the frequency and
occurs alongside migraine. There is convergence severity of attacks. The Therapeutic Guidelines has
of peripheral trigeminal sensory nerves on the recently updated its guidance on headache, including
single pain centre of the trigeminocervical complex. general principles, specific dosing recommendations,
The central mechanisms include neurotransmitter and advice for children and pregnant women.5
pathways such as serotonin, calcitonin gene-related Treating acute migraine
peptide and other neuropeptides.2
Treatments for acute migraine aim to abort the
Assessing the patient headache stage of migraine within 1–2 hours.
To distinguish migraine from other causes of Although effective for this, they do not significantly
headache, ask the patient about the character and help with the prodromal, aura or postdromal stages.
location of the headache as well as associated Treatment should be started as early as possible in
features and avoidance of exertion. Differentiating the headache phase and some patients will require a
between episodic and chronic migraine is an arbitrary combination of therapies. Common medicines used
but useful cut off for some treatment options include paracetamol, aspirin (900–1000 mg per dose)
(see Fig.). In clinical practice, patients highlight their or other non-steroidal anti-inflammatory drugs
worst migraines. To ascertain the true frequency of (NSAIDs), antiemetics and triptans.6,7
headaches, enquire about the number of completely
Triptans
headache-free days per week or month.
As they are more selective against migraine,
Management approach triptans (5HT1 agonists) may be first-line drugs
Addressing lifestyle triggers and comorbidities in for patients with moderate–severe pain, or when
patients with migraine can be particularly beneficial simple analgesics have not been effective. Triptans
for patients. Sleep disorders, dietary triggers cause vasoconstriction and are not recommended
(e.g. some types of alcohol, cheese, oranges and in patients with cardiovascular disease.8 There
chocolate), dehydration and caffeine overuse are are five triptans available in Australia. Guidelines
important to recognise and manage. Healthy body recommend trying triptans sequentially to find the

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VOLUME 43 : NUMBER 5 : OCTOBER 2020

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best tolerated and most effective option for the

Fig. Principles of migraine management
individual. Eletriptan, rizatriptan and zolmitriptan
have the highest pain-free rates at two hours and
naratriptan is associated with lower adverse effects
(see Table).2,9,10 Migraine diagnosis

Depression and anxiety are common comorbidities

with migraine. The risk of serotonin syndrome
when triptans are used in conjunction with selective
serotonin reuptake inhibitors or serotonin and
noradrenaline reuptake inhibitors is low. A recent Address lifestyle triggers
and other comorbidities
retrospective data analysis showed there were only
two confirmed cases of serotonergic syndrome in a
cohort of 19,017 patients who were co-prescribed a
triptan and an antidepressant.11
Medicine overuse can worsen migraine. Triptans should Chronic migraine (≥15 days of
Episodic migraine
therefore be limited to less than 10 days a month and headache a month, of which
8 days have migraine features)
simple analgesics to no more than 15 days a month.
Opioids are not recommended for migraine due to
limited effectiveness and the risk of drug overuse.

Managing nausea
Effective acute treatment Difficult to manage or
Intercurrent nausea can impair absorption so taking of attacks ≥3 migraines a month
an antiemetic with the first analgesic can help.12 If
patients are unable to take oral medicines, other
routes of administration can be considered:
• non-oral triptan formulations
Continue expectant • Acute medicines
• suppositories, such as NSAIDs (indometacin or management with • Prophylaxis also
diclofenac) acute medicines required
• ondansetron wafers for nausea and vomiting
• prochlorperazine suppositories.

Table Triptans available in Australia for migraine2,9,10

Generic name Formulation Dosing Initial 2-hour Sustained Tolerability

(maximum dose) relief pain free

Sumatriptan Tablet or fast disintegrating tablet 50–100 mg (300 mg/day)

Nasal spray (10 mg or 20 mg) 10–20 mg one nostril (40 mg/day) = = =

Subcutaneous injection* 6 mg autoinjector (12 mg/day)

Rizatriptan Tablet or wafer 10 mg (30 mg/day) + + =

Eletriptan Tablet 40 mg =/+ =/+ =

40–80 mg (160 mg/day)
Tablet 80 mg + + –

Zolmitriptan Tablet 2.5–5 mg (10 mg/day) = = =

Naratriptan Tablet 2.5 mg (5 mg/day) – – ++

* sumatriptan injection not subsidised on Pharmaceutical Benefits Scheme

Using 100 mg sumatriptan as the comparator:
= indicates no difference
+ indicates better
– indicates inferior, when compared with sumatriptan

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 VOLUME 43 : NUMBER 5 : OCTOBER 2020

ARTICLE Migraine management

Menstrual migraines Migraine prophylaxis

Menstrually related migraine attacks are more severe, Prophylactic therapy14,15 is generally indicated in
more difficult to treat and more likely to recur. A patients with:
combined oral contraceptive pill can be used for up • three or more severe headache days per month
to six consecutive months to limit the number and causing functional impairment that are not
choose the timing of the menstrually related attacks. consistently responsive to acute treatments
However, the combined oral contraceptive pill should
• more than 6–8 headache days per month despite
be avoided in migraine with aura due to the risk of
responsiveness to acute treatments
stroke. In addition, some patients have increased
migraine attacks on a combined contraceptive pill. • contraindications to acute migraine treatments
Non-steroidal anti-inflammatories (such as naproxen) • particularly disabling symptoms even if infrequent
may help if there are any perimenstrual symptoms, in attacks (such as brainstem aura, hemiplegic
addition to the usual acute therapies.13 migraine, syncope)
• ongoing significant impact to a patient’s
functioning despite lifestyle modifications, trigger
Box Preventive treatments for migraine management and use of acute treatments
• risk of drug overuse headache.
As first-line drugs in adults, use:
• amitriptyline* 10 mg orally, once daily at night. Increase daily dose by 10 mg at intervals Considerations for choice of preventive medicines
of at least 1 week (maximum daily dose 75 mg). Continue at maximum tolerated dose include evidence for efficacy, adverse effect
for 8 to 12 weeks to assess efficacy profile, drug interactions, contraindications, patient
OR comorbidities, costs, availability and patient
• candesartan* 4 mg orally, once daily. Increase daily dose by 4 mg at intervals of at preference.
least 1 week (maximum daily dose 32 mg). Continue at maximum tolerated dose for
8 to 12 weeks to assess efficacy
All oral prophylactic drugs for migraine were
developed for other purposes such as hypertension,
OR
• nortriptyline* 10 mg orally, once daily at night. Increase daily dose by 10 mg at intervals depression and epilepsy. In general, they alter the
of at least 1 week (maximum daily dose 75 mg). Continue at maximum tolerated dose neurotransmitters involved in migraine. Their efficacy
for 8 to 12 weeks to assess efficacy can only be fully assessed after 8–12 weeks at a
OR therapeutic dose.
• pizotifen 0.5 mg orally, once daily at night. Increase daily dose by 0.5 mg at intervals of
Antihypertensives used for prophylaxis include
at least 1 week (maximum daily dose 1.5 to 3 mg). Continue at maximum tolerated dose
for 8 to 12 weeks to assess efficacy calcium channel blockers (such as verapamil), beta
blockers (such as propranolol), and angiotensin II
OR
• propranolol 20 mg orally, once daily at night. Increase daily dose by 20 mg at intervals receptor inhibitors (such as candesartan).
of at least 1 week (maximum daily dose 160 mg in 2 or 3 divided doses). Continue at Antidepressants include amitriptyline and
maximum tolerated dose for 8 to 12 weeks to assess efficacy nortriptyline. Antiepileptic drugs are also used –
OR topiramate is the most evidence-based of the oral
• sodium valproate*† 200 mg orally, once daily at night. Increase daily dose by 200 mg at migraine preventors, but carries potential adverse
intervals of at least 1 week (maximum dose 500 mg twice daily). Continue at maximum
effects such as altered mood, verbal fluency issues
tolerated dose for 8 to 12 weeks to assess efficacy
(word finding) and paraesthesia. Sodium valproate
OR
is also prescribed as prophylaxis for migraines
• topiramate 25 mg orally, once daily at night. Increase daily dose by 25 mg at intervals
of at least 1 week (maximum dose 100 mg twice daily). Continue at maximum tolerated (see Box).5
dose for 8 to 12 weeks to assess efficacy Adverse effects and a patient’s comorbidities often
OR influence the choice of drug. For instance, medicines
• verapamil* sustained-release 90 mg orally, once daily. Increase daily dose slowly with a high risk of weight gain (e.g. pizotifen or
over 3 weeks (maximum daily dose 240 mg). Continue at maximum tolerated dose for
sodium valproate) should be avoided in obese
8 to 12 weeks to assess efficacy.
patients and beta blockers should be avoided in
those with asthma. Antihypertensive drugs should
* At the time of writing, this drug is not approved by the Australian Therapeutic Goods
Administration (TGA) for migraine prophylaxis. See the TGA website for current not be given to people with hypotension. Choosing a
information www.tga.gov.au.
sedative option at night (e.g. amitriptyline or pizotifen)
† Avoid sodium valproate in females of childbearing potential (see eTG complete
www.tg.org.au for information on teratogenic and neurodevelopmental effects of may be suitable for someone with insomnia.
antiepileptic drugs).
See eTG complete for more detailed information on migraine prophylaxis www.tg.org.au. Drugs such as propranolol and verapamil should
Reproduced with permission from Migraine [Published 2017 Nov. Amended 2019 Jan]. not be prescribed for patients with a history of self-
In: eTG complete [digital]. Melbourne: Therapeutic Guidelines Limited; 2019 Dec. poisoning. Similarly, topiramate should be avoided in
www.tg.org.au5
patients with a history of suicidal ideation.

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Botulinum toxin A fremanezumab and galcanezumab by the Therapeutic

In Australia, if a patient has chronic migraine but Goods Administration but not listed for PBS use yet
has failed to improve with three oral prophylactic in Australia, so access to this class of drug remains
medicines or could not tolerate them, they qualify limited due to cost.
for Pharmaceutical Benefit Scheme (PBS) subsidised
onabotulinum toxin A (Botox) therapy. This is given Conclusion
by a neurologist. Contrary to popular belief, this
treatment does not work by relaxing the scalp, face or Migraine management starts with a correct
neck muscles (although the latter can be of additional diagnosis. Treatment of acute attacks requires early
benefit in some patients), but rather it slowly improves and effective medicines. If simple analgesics are
the migraine frequency and severity by altering the inadequate, triptan drugs may be more effective.
neurotransmitters involved in migraine. This treatment Preventive strategies to reduce migraine attacks
requires 31 injections subcutaneously in the head and include lifestyle modifications, management
neck every three months. Overall this is well tolerated of comorbidities, behavioural and physical
without drug interactions or systemic adverse effects. therapies, and pharmacological treatments. The
However, headache, neck weakness, redness at choice of prophylactic medicines is guided by
the injection sites and heaviness of the eyelids are potential interactions, adverse effects and patient
possible adverse effects.16 comorbidities. Novel preventive therapies such as
the anti-CGRP monoclonal antibodies are targeted
Monoclonal antibodies
therapies to consider.
A new class of injectable prophylactic drugs
Managing migraine with acute and preventive strategies
targeting calcitonin gene-related peptide (CGRP)
for those significantly affected can reduce the
have emerged recently. These appear to be well
disability and loss of function caused by this disease.
tolerated and reduce migraine frequency. Erenumab
is a CGRP-receptor antibody, while fremanezumab Bronwyn Jenkins has received fees for education and
and galcanezumab target the CGRP ligand. They advisory boards from Allergan, Lilly, Novartis and Teva.
are given as monthly subcutaneous injections.17 At
the time of writing, there is approval for erenumab,

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