Expansion
Triptans are 5-HT1 agonists causing cranial vasoconstriction
Expansion
Acute treatment
- NSAIDs or aspirin with an antiemetic (metoclopramide also improves absorption by restoring gastric emptying, which is delayed in migraine)
- Triptans (sumatriptan): 5-HT1B/1D agonists causing cranial vasoconstriction and inhibiting neuropeptide release. Contraindicated in ischaemic heart disease, cerebrovascular disease and uncontrolled hypertension
- Avoid opioids, which promote medication overuse headache
Prophylaxis (considered if attacks are frequent or disabling)
- Propranolol: first line, but avoid in asthma
- Topiramate: effective but teratogenic and reduces contraceptive efficacy
- Amitriptyline, candesartan
- CGRP monoclonal antibodies for refractory cases
- Botulinum toxin for chronic migraine
Medication overuse headache is the key trap: regular analgesia on more than 10 to 15 days a month perpetuates headache, and the only treatment is withdrawal, which transiently worsens symptoms.
Combined oral contraceptives are contraindicated in migraine with aura, because of the increased ischaemic stroke risk.