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Acute Treatment for Migraine Patients

CE / CME

Strategizing Relief: Designing an Effective Acute Treatment Plan for Migraine Patients

Physician Assistants/Physician Associates: 0.50 AAPA Category 1 CME credit

Nurses: 0.50 Nursing contact hour

Physicians: maximum of 0.50 AMA PRA Category 1 Credit™

Pharmacists: 0.50 contact hour (0.05 CEUs)

Released: May 07, 2024

Expiration: May 06, 2025

Nada Hindiyeh
Nada Hindiyeh, MD, FAHS
CME/CE Information

Activity

Progress
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Course Completed

Introduction/Disease Overview: Migraine
Migraine is a complex neurologic disorder, consisting of recurrent debilitating attacks of headache that are generally associated with light and sound sensitivity or nausea, among other symptoms. It is one of the most common neurologic disorders, affecting approximately 1.1 billion people worldwide and approximately 39 million people in the United States alone.1-3 Migraine is the leading cause of years lived with disability for young women aged 15 to 49 years and the overall second leading cause of years lived with disability.4

Despite how common and disabling migraine is, it remains underdiagnosed and undertreated. Many patients with migraine cannot function normally during an attack and even report moderate to severe burden between attacks.5 To improve diagnosis of migraine, a simplified tool, the ID Migraine, was created.6 The ID Migraine can help any provider quickly and easily diagnose migraine with just 3 questions. If patients are experiencing 2 out of 3 symptoms among light sensitivity, nausea, or decreased ability to function with headache in the last 3 months, the diagnosis is likely migraine.

Once the diagnosis of migraine is made, it is important to understand the frequency and severity of attacks to distinguish between episodic migraine and chronic migraine. An individual with less frequent attacks may only require an acute treatment, whereas one with more frequent attacks may require both an acute and preventive treatment. Patients who experience 15 or more headache days per month for 3 months with symptoms of migraine (light and sound sensitivity or nausea) on at least 8 of those days would meet the criteria for chronic migraine. Those with less than 15 headache days a month would meet criteria for episodic migraine.7

Irrespective of attack frequency, all people with episodic or chronic migraine should be offered an acute treatment strategy.8 This can include over-the-counter treatment products, prescription oral, sublingual, intranasal, or injectable formulations, or noninvasive devices, and should be mutually agreed upon by patients and providers. Furthermore, if 1 treatment option alone is not enough, combinations of various acute treatments should be explored. Additional treatments to address migraine symptoms, such as antiemetics for nausea or vomiting, may also be helpful. However, it is important to have your patient document the use of acute treatments, as some may cause medication overuse headache and should not be overused.9

Case Presentation
Alice N. is a 42-year-old woman who presents to your clinic with a history of headaches since the age of 14. Her headaches are described as throbbing and squeezing, holocephalic, and associated with nausea and light sensitivity. Alice was initially relieved by 400 mg of ibuprofen, but since last year this is no longer helpful. She reports her nausea has worsened and that she now has vomiting with these headaches, which occur approximately 3 times per month and last 24 hours. She still takes ibuprofen and acetaminophen, with only mild benefit, and finds it difficult to keep them down due to nausea and vomiting. She is unable to function for most of the day when she has a headache, often missing work and finding it difficult to take care of her 2 young children. She has no other medical diagnoses.

Physical Exam:

  • Vital signs: normal
  • Neurologic exam: normal

Lab Values (ordered by her PCP):

  • Normal CBC, BMP, vitamin D, B12
  • CT head noncontrast: no intracranial abnormalities noted

Family History:

  • Both her mother and sister have frequent headaches associated with nausea and light sensitivity

Lifestyle/Social History:

  • Sleeps from 10 pm to 6 am daily
  • Does mild aerobic exercise twice/week
  • Drinks 1 cup of coffee daily
  • Does not skip meals and stays well hydrated

Current medications:

  • Ibuprofen 800 mg 3 times/month
  • Acetaminophen 500 mg 3 times/month

What diagnosis best fits Alice’s description?