Migraine headache in adults

Discuss goals of treatment with the patient. Explain treatment options (both drug and non-pharmacological therapies), including risks and benefits of each, and take patient preferences and values into account in treatment decisions.[34]Ailani J, Burch RC, Robbins MS, et al. The American Headache Society consensus statement: update on integrating new migraine treatments into clinical practice. Headache. 2021 Jul;61(7):1021-39. https://www.doi.org/10.1111/head.14153 http://www.ncbi.nlm.nih.gov/pubmed/34160823?tool=bestpractice.com [82]Ashina M, Buse DC, Ashina H, et al. Migraine: integrated approaches to clinical management and emerging treatments. Lancet. 2021 Apr 17;397(10283):1505-18. http://www.ncbi.nlm.nih.gov/pubmed/33773612?tool=bestpractice.com ​​[235]Urtecho M, Wagner B, Wang Z, et al. A qualitative evidence synthesis of patient perspectives on migraine treatment features and outcomes. Headache. 2023 Feb;63(2):185-201. https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.14430 http://www.ncbi.nlm.nih.gov/pubmed/36602191?tool=bestpractice.com

Advise patients with migraine of the following:[34]Ailani J, Burch RC, Robbins MS, et al. The American Headache Society consensus statement: update on integrating new migraine treatments into clinical practice. Headache. 2021 Jul;61(7):1021-39. https://www.doi.org/10.1111/head.14153 http://www.ncbi.nlm.nih.gov/pubmed/34160823?tool=bestpractice.com [129]Seng EK, Martin PR, Houle TT. Lifestyle factors and migraine. Lancet Neurol. 2022 Oct;21(10):911-21. http://www.ncbi.nlm.nih.gov/pubmed/36115363?tool=bestpractice.com ​

• Do not delay treatment. To be as effective as possible, it is important that treatment is started at the first signs of a migraine attack, before pain is severe. Delaying treatment may result in medications being less effective, with a greater likelihood of nausea developing and the attack lasting longer than it might otherwise.

• Try to maintain a lifestyle that may help to avoid migraines: do not skip meals, keep a regular schedule, get enough sleep, avoid getting dehydrated, take regular exercise, and identify and avoid specific migraine triggers.

• Keeping a headache diary is a good way of identifying triggers, helping to recognise warning signs that an attack is starting, recording symptoms, and assessing whether medication is working.​ Migraine Trust: keeping a headache diary Opens in new window

• Cognitive behavioural therapy, biofeedback, relaxation training, mindfulness-based therapies, other psychological therapies, exercise, or acupuncture may help to reduce migraine frequency and severity for some people.

• Excessive use of medication can result in medication-overuse headache.

Inform any women of childbearing age that they must follow a pregnancy prevention programme while on treatment with valproate medicines. The European Medicines Agency states that this programme should include:[236]European Medicines Agency. New measures to avoid valproate exposure in pregnancy endorsed. EMA/145600/2018. Mar 2018 [internet publication]. http://www.ema.europa.eu/docs/en_GB/document_library/Press_release/2018/03/WC500246391.pdf

• An assessment of the patient’s potential for becoming pregnant

• Pregnancy tests before starting (and during) treatment as needed

• Counselling about the risks of valproate treatment and the need for effective contraception throughout treatment

• A review of ongoing treatment by a specialist, at least annually

• A risk acknowledgement form that patients and prescribers can go through at each annual review to confirm that appropriate advice has been given and understood.