Migraines can be disabling for those affected, but various pharmacologic and nonpharmacologic therapies are available.
Twelve percent of the US population experiences migraine, according to the Migraine Research Foundation. Migraine is the third most prevalent illness globally, and it affects 1 out of 4 US households. Moreover, migraine can be disabling, with 90% of those affected worldwide unable to work or function normally during a migraine attack.1
Migraine Phases and Symptoms
Although migraine is sometimes thought of as just a headache, a migraine attack can involve 4 phases of various symptoms. Not every stage is present in every migraine. Pharmacists can counsel patients to keep track of their migraines with a headache journal or app because neurologists and headache specialists may be able to pinpoint patterns and detect a migraine attack before it arrives.2
A migraine attack can manifest with any of the 4 phases:
One way to remember migraine symptoms is with the acronym POUND3:
P: pulsating pain
O: 1-day duration of severe untreated attacks
U: unilateral pain
N: nausea and vomiting
D: disabling intensity
When to Consult a Specialist
It is prudent to refer patients who have frequent headaches, headaches that are increasing in severity or frequency, or headaches that interfere with functioning to a headache specialist for evaluation and a treatment plan, including preventive and acute treatment.4
If the patient experiences a new or unusual symptom, such as a headache that occurs within a few seconds or the worst headache they’ve ever had, refer the patient to the emergency department. Other symptoms that require emergency treatment include pain for more than 72 hours, fever, weakness, vision loss or changes, and confusion or if the patient is pregnant, is immunocompromised, or has a severe medical condition like liver or kidney disease.4,5
Nonpharmacological prevention of migraine
Some nonpharmacological migraine prevention tips for patients include6,7:
Pharmacological prevention of migraine
Patients who have 4 or more migraine attacks, 8 or more migraine days per month, or other qualifying factors may need preventive treatment.7 Many options are available, and some of the more common preventive treatment medications include the following7:
β-Blockers (propranolol or metoprolol)
Anticonvulsants (divalproex or topiramate)
Antidepressants (such as amitriptyline or venlafaxine)
Calcitonin gene-related peptide (CGRP) inhibitors are a newer class of drugs that prevent migraine by targeting CGRP, which is found in higher levels during a migraine attack. CGRP inhibitors are monoclonal antibodies that block the effects of CGRP and are the first class of medications specifically designed to prevent migraine.
CGRP inhibitors approved by the FDA for the prevention of migraine are as follows8-12:
Common AEs associated with CGRP inhibitors include injection-site reactions (pain, redness, itching) and hypersensitivity reactions.9-12 Other AEs of erenumab-aooe include constipation (possibly with complications including hospitalization) and increased blood pressure.9 Eptinezumab-jjmr may also cause nasopharyngitis.13
Many options are available for migraine treatment. Product selection may be based on a variety of factors, including symptoms, medical history, other medications, patient preference for specific formulation(s), AEs, and cost or insurance considerations (TABLE).14
Pharmacists can provide counseling on the following popular first-line medications for migraine treatment.
For mild to moderate migraine attacks, acetaminophen and oral nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, diclofenac, ibuprofen, or naproxen may be used. Although acetaminophen is less effective than NSAIDs for migraine, it has fewer AEs. The combination in acetaminophen/aspirin/caffeine (Excedrin; Novartis) is also a first-line option.14
Counseling can include dosage, limitations, and the importance of avoiding alcohol. For NSAIDs and acetaminophen/aspirin/caffeine, also counsel patients on the risk of potential gastrointestinal and cardiovascular effects.15
Triptans are effective as a first-line treatment for moderate to severe migraine. Triptans approved by the FDA for the treatment of migraine include the following14:
Triptans have slight differences that may cause patients to respond to certain triptans but not others. Triptans are most effective when taken early in a migraine attack and are generally well tolerated. Most triptans, with the exception of almotriptan and frovatriptan, can cause fatigue, dizziness, chest pain, and nausea.14
Do not use opioids or butalbital for migraine except as a last resort.
Do not prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders.
Do not recommend prolonged or frequent use of OTC pain medications for headache.
American Academy of Neurology
American Headache Society
American Headache Society
Other new drugs have entered the market for migraine prevention and/or treatment.
An important consideration when talking with patients is the possibility of medication-overuse headache, also known as a rebound headache—part of a vicious cycle of having headaches and taking more and more medication to relieve them, which results in near-daily or daily headaches.16
Patients who experience headaches every day, or almost every day, especially when the pain begins upon awakening, may be experiencing a medication-overuse headache. Refer the patient to a headache specialist, who can help the patient establish a new treatment plan that includes stopping acute medications, starting preventive treatment, and slowly reintroducing a limited amount of acute medicines as needed.16
Drug Interactions and Serotonin Syndrome
An essential consideration in either preventive or acute treatment is the presence of drug interactions. Pharmacists can help patients by checking for drug interactions and being especially aware of the possibility of serotonin syndrome, a life-threatening condition that is more likely to occur with triptans and other medications that increase serotonin levels.