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Migraine Management: Selecting NSAIDs, Acetaminophen (For mild to moderate pain), and Triptans (For moderate to severe pain) not only treat pain but also prevent it with Propranolol.

Medication

Indication

Examples

Typical Dose

Notes

NSAIDs

Mild to moderate pain

Ibuprofen, Naproxen

Ibuprofen: 400-600 mg every 6-8 hours<br>Naproxen: 250-500 mg twice a day

Max daily limit: Ibuprofen 3200 mg, Naproxen 1000 mg

Acetaminophen

Mild to moderate pain

Tylenol (Paracetamol)

500-1000 mg every 4-6 hours

Max daily limit: 4000 mg

Triptans

Moderate to severe pain

Sumatriptan, Rizatriptan

Sumatriptan: 25-100 mg at onset<br>Rizatriptan: 5-10 mg at onset

Use at the onset of migraine symptoms

Propranolol

Preventive treatment

N/A (used for prevention)

20-160 mg daily in divided doses

Dose adjusted based on response and side effects


Cinematic depiction of a person experiencing a migraine, highlighted by contrasts of light and dark, with abstract elements symbolizing pain and relief.
A cinematic and realistic portrayal of a person experiencing a migraine, highlighted by dramatic contrasts of darkness and light. The central figure is depicted holding their head in anguish amidst abstract elements symbolizing the intense and overwhelming nature of migraine symptoms. Visual metaphors such as pulsating lights and jagged lines represent the throbbing pain, while a clock or an hourglass signifies the enduring nature of the attack. The image captures the struggle and resilience of individuals facing migraines, set in a landscape orientation to emphasize the breadth of the experience.


Migraine management is a stepwise approach tailored to the severity and frequency of headache episodes, as well as the patient's response to treatment. The goal is to reduce the frequency, severity, and duration of migraine attacks and improve the patient's quality of life. Treatment can be divided into acute (abortive) and preventive (prophylactic) strategies.


Acute Treatment:

The aim of acute treatment is to stop or reduce the severity of a migraine attack once it has started.

First-line options for mild to moderate migraine attacks include:

  • NSAIDs (Nonsteroidal Anti-Inflammatory Drugs): Ibuprofen, naproxen, and aspirin are effective in reducing migraine pain and associated symptoms.

  • Acetaminophen (Paracetamol): Can be used alone or in combination with caffeine or an NSAID.

For moderate to severe migraines, or if NSAIDs and acetaminophen are ineffective, the first-line options are:

  • Triptans: Sumatriptan, rizatriptan, naratriptan, and others. Triptans are serotonin receptor agonists that reduce inflammation and constrict blood vessels.

  • Ergots: Ergotamine and dihydroergotamine (DHE), which are less commonly used due to their side effects but can be effective for some patients.


Side Effects of Ergot


For nausea and vomiting, adjunctive treatments include:

  • Anti-nausea medications: Metoclopramide, prochlorperazine, or ondansetron.

Preventive Treatment:

Preventive treatment is considered if migraines are frequent, typically more than four times a month, or if acute treatments are ineffective.

First-line options for preventive treatment include:

  • Beta-blockers: Propranolol and metoprolol have been shown to reduce the frequency and severity of attacks.

  • Anticonvulsants: Topiramate and valproate are effective for migraine prevention.

  • Calcium channel blockers: Verapamil is used to prevent migraines in some patients.

  • Antidepressants: Amitriptyline, a tricyclic antidepressant, is often used for migraine prevention, especially if the patient also has depression or insomnia.

Newer options include:

  • CGRP (Calcitonin Gene-Related Peptide) antagonists: Erenumab, fremanezumab, and galcanezumab are monoclonal antibodies designed to prevent migraines by targeting the CGRP pathway, which is involved in the development of migraine pain.

Lifestyle modifications and non-pharmacological treatments should also be part of the management plan. This includes regular exercise, maintaining a healthy diet, ensuring adequate hydration, stress management techniques, and avoiding known migraine triggers.

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