Migraine/Headache

• Migraines are more common in females than males
• Young people tend to get migraines more often, less common in the 60s-70s
• An aura occurs in around 30% of migraine patients
• Migraine triggers

  • Stress
  • Meal-skipping (consider food insecurity)
  • Foods (e.g. chocolate or soft cheese)
  • Alcohol (especially red wine)
  • Caffeine withdrawal
  • Dehydration
  • Menstruation
  • Lights/sunlight
  • Erratic sleep/shift work
  • Perfume/odour
  • Obesity
  • Change in barometric pressure
• Standard therapies & combos

  • Naproxen 500-825mg: 45% pain relief at 2 hours vs placebo 28% (NNT=5.8)
  • Acetaminophen: 52% pain relief at 2 hours vs placebo 32% (NNT=5)
  • Ibuprofen 400mg: 57% pain relief at 2 hours vs placebo 25% (NNT=3.1)
  • Oral triptan, standard dose: 57% pain relief at 2 hours vs placebo 32% (NNT=4)
  • NSAID + oral triptan: 58% pain relief at 2 hours vs placebo
• Simplified pathophysiology of a migraine

  1. Some people have sensitized neurons - unclear why

  2. A migraine trigger comes along (e.g. stress, dehydration, lack of sleep, or completely unidentifiable)

  3. The brain releases potent vasodilators (e.g. CGRP, nitric oxide) and inflammation reactions

  4. Vasodilation = big pain; inflammation begets more inflammation

  5. Triptans = selective serotonin agonists = vasoconstrictors

  6. NSAIDs = anti-inflammation

  7. Anti-CGRP = prevent/reduce vasodilation

  8. Early treatment = nip it in the bud = better efficacy
• Migraine Aura possible symptoms

  • Visual Aura (e.g. flickering bright lines, blind spots, lightning bolts)
  • Sensory Disturbances (e.g. tingling, numbness, pins and needles)
  • Speech Disturbances (e.g. difficulty word-finding)
• Medications for migraine relief

  • Naproxen 500-825mg
  • Acetaminophen
  • Ibuprofen 400mg
  • Oral triptan, standard dose
  • NSAID + oral triptan
  • Oral triptan, high dose
  • Acet 1000mg + metoclop
  • Intranasal triptan, high dose
  • Subcut sumatriptan
  • Acet500 + ASA500 + caffeine130
• Opioids have double the risk of medication overuse headache compared to other agents
• Codeine metabolism is unpredictable
• Triptans are potent vasoconstrictors
• Triptans can cause chest discomfort/tightness, palpitations, dizziness, facial flushing
• Triptans are contraindicated in cardiovascular disease and within 24 hours of ergots
• Triptans are potent serotonin agonists
• Triptans can cause nausea
• Triptans are contraindicated with MAOIs and cautioned with other serotonin drugs
• The highest efficacy triptan is subcutaneous sumatriptan
• Try a triptan for 3 migraines before giving up, and try at least 3 triptans before giving up on the class
• Acetaminophen alone or in combination can be helpful for migraines
• Nausea/vomiting is common with migraines
• ODT triptans are no faster than regular tabs
• Max days per month of acute medications to help avoid medication overuse headache

  • Triptans: 9 days
  • Opioids: 9 days
  • NSAIDs or acetaminophen: 1-4 days
  • Multiple classes: 9 days
• For some, migraines increase during menstruation
• Option for pre-treatment for menstrual migraines starting ~2 days before
• Max days per month of acute medications to help avoid medication overuse headache

  • Triptans: 9
  • Opioids: 9
  • NSAIDs or acetaminophen: 1-4
  • Multiple classes: 9
• Menstrual migraine: For some, migraines occur during menstruation (perhaps due to changing hormone levels)
• Option for pre-treatment during menstruation

  1. Naproxen 500mg BID x ~6 days ($5)

  2. Naratriptan 1mg BID x ~6 days ($100)

  3. Frovatriptan 2.5mg BID x ~6 days ($200)

  4. Estradiol gel 1.5mg daily x ~7 days ($40)
• Option for prevention with continuous combined hormonal contraceptives. However, CHCs + migraine with aura are contraindicated
• CHCs + migraine with aura + smoking

  7x stroke risk
• New 'pants' for acute migraine: CGRP receptor antagonists
• New CGRP medications

  • Ubrogepant approved in Canada 2022
  • Rimegepant and Zavegepant approved in USA (not yet in Canada)
  • Atogepant approved in Canada for prevention of migraines
• Treatment dose for Ubrogepant

  50-100mg stat; NNT=8 vs placebo
• Prevention dose for Atogepant 10 - 60 mg daily
• Adverse effects of Atogepant: nausea, somnolence. Not contraindicated in CV disease. Likely NOT as effective as triptan for acute migraine, although not compared head-to-head. Appears to have very low risk of medication-overuse headache
• Migraine (with or without aura):

  • duration: 4 - 72 hours
  • location: Typically unilateral (but 40% bilateral)
  • pain: Usually pulsating pain; moderate to severe intensity,
  • symptoms, patients experience at least one of: nausea, vomiting, photophobia, and/or phonophobia. Can be aggravated by routine physical activity.
• Symptoms of moderate to severe intensity headache

  • Nausea
  • Vomiting
  • Photophobia
  • Phonophobia
• Aura


  May include reversible visual symptoms (e.g. flickering lights, spots, or lines; loss of vision), reversible sensory symptoms (e.g. pins & needles, numbness), or reversible dysphasic speech disturbance. Each aura symptom may last 5-60 minutes
• Treatment options for migraines

  • NSAID
  • Triptan
  • Acetaminophen
  • Anti-emetic
  • DHE
• Prophylaxis options for migraines:

  • TCA
  • Beta-blocker
  • Topiramate
  • Candesartan
  • Venlafaxine
  • Anti-CGRP
  • Some herbals
• Tension-Type headache lasts from 30 minutes to 7 days