Migraines

Diagnosis

• Clinical Criteria (adapted from ICHD-3):

  • Headache lasts 4–72 hours (untreated or unsuccessfully treated)

  • ≥2 of the following:

    • Unilateral location

    • Pulsating quality

    • Worsened by routine physical activity

    • Moderate or severe intensity

  • ≥1 of the following:

    • Nausea ± vomiting

    • Photophobia and/or phonophobia

• Exclude secondary headache causes (e.g. tumour, infection, giant cell arteritis)

Management

Non-Pharmacological

• Limit Caffeine: Watch for triggers (chocolate, certain perfumes)

• Regular Sleep: Maintain consistent sleep times

• Relaxation Therapy: CBT, meditation, yoga, breathing exercises

• Hydration, Regular Meals: Avoid hypoglycaemia triggers

• Low-Impact Aerobic Exercise: ~150 min/week (walking, swimming)

• Workplace Ergonomics: Address neck tension, physiotherapy if needed

• Magnesium 500 mg daily (3-month trial; evidence limited but commonly used)

• Ice Pack to neck or forehead during flares

• Avoid Analgesic Overuse: Limit painkillers to <10–15 days/month (prevent medication overuse headache)

• Avoid Opioids/Codeine: Risk of overuse, dependence, and analgesic rebound

Stepwise Pharmacological Approach

1. Non-Opioid Analgesic

   • Ibuprofen 400 mg (adult) or 10 mg/kg (child), or paracetamol as alternative

   • Combine with antiemetic (e.g. ondansetron 8 mg adult or ~0.1 mg/kg in children) → Can enhance analgesic absorption even if no nausea

2. Triptans (e.g. sumatriptan)

   • Sumatriptan 50 mg PO → can repeat in 2 hrs if effective.

   • Intranasal sumatriptan 20 mg (adults/children) for those with severe nausea/vomiting

   • If no initial response to triptan → do NOT repeat.

   • If positive response → may repeat in 2 hours if recurrence.

   • Caution with SSRI/SNRI (serotonin syndrome risk is low but possible).

Prophylaxis (if >2 disabling attacks/month)

• Amitriptyline: 10 mg up to 75 mg daily. Trial a max tolerated dose for 8–12 weeks.

• Propranolol: 20 mg nocte (only prophylactic proven in children).

• CBT or other psychological support can reduce stress-related triggers.

Notes

• Riboflavin (vitamin B2) and ubidecarenone (coenzyme Q10) can be tried for 3 months.

• Avoid aspirin <16 years (Reye’s syndrome risk).

• Sumatriptan is the only triptan available in injectable/intranasal form in Australia.

• Tension headache prophylaxis: amitriptyline.

• Tremor/vestibular migraine: Propranolol.

• Migraine-specific prophylaxis: Pizotifen an option.

Migraine Prophylaxis – Choosing Medications

Explanation

• Propranolol may help with anxiety, tremor, but avoid in asthma.

• Topiramate beneficial for weight control/obesity but avoid with kidney stones.

• Valproate is typically avoided in women of childbearing potential due to teratogenicity (and in some guidelines also for obesity).

• TCAs can help insomnia or fibromyalgia (sedative and analgesic synergy)