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2019 Migraine prevention and

treatment guidelines: American
Headache Society

M3 India Newsdesk Apr 01, 2019

Summary

The comprehensive guidelines

developed by AAN and American
Headache Society cover,

migraine prophylactic and acute

therapy
 recommendations for episodic
prevention in adults
advice on NSAIDs usage and
complementary treatment options

The American Headache Society (AHS)

has recently updated its migraine
prevention and acute treatment
guidelines in 2019. Treating migraine
not only involves steps that lessen
migraine triggers, but in people that
have regular attacks, treatment
includes acute or abortive therapy, and
also prophylactic or preventive therapy.

American Headache Society

preventive migraine treatment
guidelines

Preventive treatment is given to lessen

the frequency and severity of the
migraine attack when there is no
headache present. The guidelines
suggest the treatment for:

Anyone that has 4 or more

migraine attacks per month and/or
if their normal functioning and
daily routine is being negatively
affected by the migraine attacks
 even after acute treatment
In patients, if there is overuse,
frequent failure, intolerable
adverse effects, or
contraindications to acute
treatment

Medications include oral therapy with

antiepileptic drugs (AEDs), beta
blockers, tricyclic antidepressants,
calcium channel blockers, selective
serotonin reuptake inhibitors (SSRIs),
NSAIDs, serotonin antagonists,
botulinum toxin, and calcitonin gene-
related peptide (CGRP) inhibitors.
Preventive therapy also makes it more
likely that when the attack occurs, it is
more responsive to abortive therapy
and also betters the patient's quality of
life.

Precautions
 1. Anti-epileptics like valproate
sodium and topiramate should not
be prescribed to women who can
conceive, and to those not using
birth control.
2. Adverse effects of migraine drugs
may occur during treatment and
therefore oral treatment should be
started at a low dose and the
dosages should be slowly
increased over at least a
minimum of 8 weeks for optimal
therapeutic result.

AHS acute migraine treatment

guidelines

Abortive or acute therapy mediation

involves selective serotonin receptor (5-
HT1) agonists (triptans), ergot
alkaloids, analgesics, nonsteroidal anti-
inflammatory drugs (NSAIDs),
combination products and antiemetics.
It is given after the headache has
started with an aim to reduce or stop
the headache.

1. At the earliest sign of a migraine

attack, evidence-based treatment
should be initiated.
2. Mild to moderate attacks should
be treated with NSAIDs (including
aspirin), nonopioid analgesics,
acetaminophen, or caffeinated
analgesic combinations.
3. Mild to moderate attacks that
poorly respond to NSAIDs or
caffeinated combinations and
moderate or severe attacks
should be treated with migraine‐
specific agents such as triptans
and dihydroergotamine.
 4. In patients experiencing nausea
or vomiting, or difficulty in
swallowing, a non-oral route of
medication administration should
be chosen. SC sumatriptan, DHE
injection or intranasal spray, or
corticosteroids are possible
outpatient rescue options
whereas parenteral formulations
of triptans, DHE, antiemetics,
NSAIDs, anticonvulsants (eg,
valproate sodium and topiramate,
except in women of childbearing
age who are not using reliable
birth control), corticosteroids, and
magnesium sulfate are possible
inpatient rescue options.

Episodic migraine prevention

in adults
The American Academy of Neurology
and the American Headache Society,
have put forward pharmacologic
treatment guidelines for episodic
migraine prevention in adults.

1. Level A recommendations;
effective medicines that should be
offered for migraine prevention
include,

antiepileptic drugs (AEDs)

such as divalproex sodium,
sodium valproate and
topiramate
triptans such as frovatriptan
for preventing menstrually
associated migraine (MAM)
β-Blockers such as
metoprolol, propranolol and
timolol
2. Level B recommendations;
probably effective and should be
considered medications include,

antidepressants such as
amitriptyline, venlafaxine
β-blockers such as atenolol,
nadolol
triptans such as naratriptan,
zolmitriptan for short-term
MAM prevention

3. Level C recommendations;
medications that are possibly
effective and may be considered
include,

ACE inhibitors such as

lisinopril
angiotensin receptor
blockers such as
candesartan
 α-agonists such as
clonidine, guanfacine
AEDs such as
carbamazepine
β-Blockers such as
nebivolol, and pindolol

Use of NSAIDs/complementary
treatments for episodic migraine
prevention in adults

Level A recommendations
(effective and should be offered):
Petasites (butterbur)
Level B recommendations
(probably effective and should be
considered): NSAIDs such as
fenoprofen, ibuprofen, ketoprofen,
naproxen, naproxen sodium,
herbal therapies, vitamins, and
minerals such as riboflavin,
 magnesium, MIG-99 (feverfew)
and histamines SC
Level C recommendations
(possibly effective and may be
considered): NSAIDs such as
flurbiprofen, mefenamic acid,
herbal therapies, vitamins, and
minerals: Co-Q10, estrogen and
antihistamines such as
cyproheptadine

Other therapy considerations

1. More than 90% of patients with a

headache that goes to the
emergency department are found
to have migraine, tension, or
mixed-type benign headache and
giving symptomatic pain relief
should be a top priority.
 2. Keeping the patient in a quiet dark
room is beneficial.
3. Applying cool compresses to
painful areas may also help.
4. Pain killers and narcotics are the
mainstays of pain relief
management but narcotics are
mainly ineffective for patients with
migraine in the ED.
5. If required, patients with migraine
should be taken to the emergency
department with minimal visual
and auditory stimulation and until
a thorough neurologic
examination has been conducted
by a trained specialist, opioids
should not be given to most
patients.

Migraine triggers
Identifying and avoiding migraine
triggers (eg, lack of sleep, fatigue,
stress, certain foods, use of
vasodilators, OCP, HRT) is an effective
cheap alternative that goes a long way
in migraine management. Patients with
migraine should be screened and
actively treated for cardiovascular risk
factors.

Patients with migraine and aura should

be warned about the greater risk of
stroke associated with smoking or
taking oral contraceptive pills. If
clinically required, a specialist such as
a neurologist, neuro-ophthalmologist,
and/or neurosurgeon should assist with
the management of the patient with
migraine.
Hospital admission

Migraine patients may require hospital

admission and treatment under these
criteria:

Severe nausea, vomiting, and

dehydration
Severe, refractory migraine pain
(i.e. status migrainosus)
Combination analgesics, ergots,
or opioid detoxification after
overuse

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