Diagnosis and acute management of migraine

Article Figures & Tables

Table 1:

Headache red flags — modified SNOOP420^,21

	Red flag	Clinical features	Etiologies to exclude
S	Systemic signs, symptoms or disease	Fever, weight loss, HIV, immunosuppression, malignancy, pregnancy or postpartum	Metastatic disease, CNS infection, CVST, RCVS, IIH
N	Neurologic symptoms or signs	Neurologic deficits or atypical or prolonged neurologic symptoms, or both	Neoplastic, inflammatory, infectious or vascular CNS disease
O	Onset (late)	Headache onset after age 50 yr	Neoplastic, inflammatory or infectious CNS disease; giant cell arteritis
O	Onset (sudden)	Thunderclap headache with onset to maximum intensity in < 60 s	Subarachnoid hemorrhage, CVST, RCVS, arterial dissection
P	Papilledema	Optic disc swelling (with or without pulsatile tinnitus, diplopia, transient visual obscuration, weight gain)	Raised intracranial pressure (mass lesion, hemorrhage, edema, CVST, IIH)
P	Postural aggravation	Headache worsened or triggered by standing or lying down	Intracranial hypotension (cerebrospinal fluid leak), intracranial hypertension (IIH, mass lesion)
P	Precipitated by valsalva	Headache triggered by valsalva (coughing, exercise or intercourse)	Chiari malformation, mass lesion (e.g., posterior fossa)
P	Pattern change or progressive	Change in previously stable pattern (loss of headache-free periods) or progressively worsening headache with evolving clinical symptoms	Any secondary cause

Note: CNS = central nervous system, CVST = cerebral venous sinus thrombosis, IIH = idiopathic intracranial hypertension, RCVS = reversible cerebral vasoconstriction syndrome.

Table 2:

Traditional medications for acute migraine treatment26

Drug category	Drug(s)	Canadian Headache Society
Drug category	Drug(s)	Level of evidence^*	Strength of recommendation^†
Recommended for use in episodic migraine
Triptans	Almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan	High	Strong
Acetaminophen and NSAIDs	Acetaminophen, acetylsalicyclic acid, diclofenac potassium, ibuprofen, naproxen sodium	High	Strong
Combination analgesics	Naproxen–sumatriptan	High	Strong
Anti-emetics (adjunct)	Metoclopramide	Moderate	Strong
Anti-emetics (adjunct)	Domperidone	Low	Strong
Ergots	Dihydroergotamine (nasal, subcutaneous)	Moderate	Weak
Not recommended for routine use in episodic migraine^‡
Ergots	Ergotamine	Moderate	Weak
Opioids and tramadol	Opioids or opioid-containing combination analgesics	Low	Weak
Opioids and tramadol	Tramadol or tramadol-containing combination analgesics	Moderate	Weak
Not recommended for use in episodic migraine^§
Synthetic opioids	Butorphanol nasal spray	Low	Strong against
Barbiturates	Butalbital-containing combination analgesics	Low	Strong against

Note: GRADE = Grading of Recommendations Assessment, Development and Evaluation, NSAID = nonsteroidal anti-inflammatory drug.
↵* Levels of evidence using the GRADE system: high = the guideline authors are confident that the true effect lies close to the estimate given by the evidence available; moderate = the guideline authors are moderately confident in the effect estimate, but there is a possibility it is substantially different; low = the confidence in the effect estimate is limited and the true effect may be substantially different; very low = the guideline authors have little confidence in the effect estimate.
↵† Recommendation categories using the GRADE system: strong = benefits clearly outweigh risks and burdens for most patients; weak = the balance between benefits and risks is narrow and there is uncertainty about when it should be used.
↵‡ Not recommended for routine use but may be considered for occasional use when other medications have failed.
↵§ Should be avoided except in exceptional circumstances.
Adapted with permission from Worthington I, Pringsheim T, Gawel MJ, et al.; Canadian Headache Society guideline: acute drug therapy for migraine headache. Can J Neurol Sci 2013;40(Suppl 3):S1–80.

Table 3:

New pharmacologic therapies for acute treatment of migraine, with or without aura

Drug	Ubrogepant	Rimegepant^*	Lasmiditan^†
Mechanism of action	CGRP receptor antagonist	CGRP receptor antagonist	5-HT1F receptor agonist
Dosing	Oral: 50 or 100 mg as needed (max 2 doses/24 h)	Oral or sublingual: 75 mg as needed (max 1 dose/24 h)	Oral; 50, 100 or 200 mg as needed (max 1 dose/24 h)
Adverse effects	Nausea, dizziness and dry mouth	Nausea and abdominal pain and dyspepsia	Dizziness, drowsiness, paresthesia, nausea, vomiting and muscle weakness

Note: CGRP = calcitonin gene-related peptide.
↵* Rimegepant is not yet approved in Canada.
↵† Lasmiditan is not expected to be coming to the Canadian market at the present time. Label warning: avoid driving within 8 hours of its use.