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

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

Ergot derivatives, such as ergotamine and dihydroergotamine (DHE), are classic medications used for the treatment of migraine. They work primarily through potent vasoconstriction, reducing the blood vessel dilation associated with migraine headaches. However, their use has been superseded by medications with fewer side effects, like triptans, due to the significant adverse effects and contraindications linked to ergot derivatives. Here is an updated, comprehensive overview of the side effects associated with ergot derivatives:

Common Side Effects:

• Nausea and Vomiting: A frequent side effect due to gastrointestinal irritation, complicating treatment for many patients.

• Muscle Pain and Cramps: Manifestations of ergotism include severe muscle pain, cramping, and paresthesias (sensations of tingling, pricking, or numbness of the skin).

• Numbness and Tingling: Caused by peripheral vasoconstriction leading to reduced blood flow to extremities, resulting in sensations of cold, numbness, and tingling.

• Weakness: Generalized weakness may occur, affecting patients' overall physical condition and stamina.

Severe Side Effects:

• Ergotism: The most notorious adverse effect, characterized by intense arterial vasoconstriction, leading to ischemia. Symptoms can include severe pain, necrosis, and in extreme cases, gangrene of the extremities.

• Vascular Events: The vasoconstrictive action of ergot derivatives increases the risk of serious vascular complications, such as myocardial infarction, stroke, and peripheral vascular ischemia, especially in patients with underlying cardiovascular conditions.

• Rebound Headaches: Overuse can lead to medication-overuse headaches, worsening the headache cycle and frequency.

Vasoconstrictive Effects:

• Mechanism: Ergot derivatives exert their therapeutic and adverse effects primarily through vasoconstriction. They activate serotonin (5-HT) receptors and alpha-adrenergic receptors on vascular smooth muscle cells, leading to narrowed blood vessels.

• Consequences: While this mechanism can alleviate migraine pain by countering vasodilation, it can also significantly reduce blood supply to peripheral tissues and organs, leading to the risk of ischemia and other vascular events.

Monitoring and Contraindications:

Due to these side effects, ergot derivatives are contraindicated in patients with peripheral vascular disease, coronary artery disease, and during pregnancy. They are generally considered a second-line or reserve treatment for patients who do not respond to or cannot take other medications. It is crucial to monitor patients closely if ergot derivatives are used, especially those with a history of vascular disease, to mitigate the risk of significant adverse effects.

In summary, while ergot derivatives have played a historical role in migraine management, their use today is limited by their side effect profile. The decision to use these medications should be carefully considered, with a preference for newer agents with fewer adverse effects when possible.

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.