General Principles of Migraine Management

There are few important aspects for management of migraine headache, which should be kept in mind while treating (managing) a patient with migraine headache. The most important aspect in the management of migraine headache is educating the patient about the reality of migraine headache. It is generally helpful to educate the patient about migraine and to make the patient understand that migraine is an inherited tendency to headache and that migraine can be modified and controlled by lifestyle modifications (adjustments) and medications, but it cannot be eradicated or cured. It is also important to educate the patient that migraine is not associated with serious or life-threatening illnesses, except in some occasions in women who are on oral estrogens or on oral contraceptives.

The next principle of management of migraine is to try to manage migraine by non pharmacological (non drug) approach. For non drug management of migraine yoga, meditation, hypnosis, and conditioning techniques can be used. These techniques will reduce stress or help to cope with stress better, because over responsiveness to stress is one of the important triggering factors of migraine.

If migraine can not be managed the next approach should be to start preventive treatment of migraine. Preventive treatment of migraine is generally done with low dose amitriptyline (tricyclic antidepressant drug), propranolol (beta blocker), topiramate, gabapentin, or valproate etc. The success with any of these drugs is approximately 50% – 70%. If these drugs fail or lead to unacceptable side effects, second-line agents like methysergide or phenelzine can be tried. If effective stabilization is achieved with any drug, the drug is continued for 5 to 6 months and then slowly tapered.

If preventive treatment fails (generally most of the patients can be managed and are managed by preventive treatment), than treatment should be aimed at aborting an acute attack by vigorous treatment of the symptom of headache.