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Migraine

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Updated 2024 VA/DoD guidelines for the management of migraine.

Background

Overview

Definition
Migraine is a primary headache disorder characterized by recurrent moderate-to-severe headaches, often accompanied by nausea, vomiting, and/or sensitivity to light and sound.
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Pathophysiology
Migraine is due to complex brain network disorder involving the cortex, hypothalamus, thalamus, and brainstem in genetically predisposed individuals.
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Epidemiology
The overall prevalence of migraine over a 3-month period in the US adult population is 15.3%, affecting approximately 20.7% of females and 9.7% of males. The global lifetime prevalence of migraines is estimated at 14%.
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Disease course
The complex interplay between cortex, hypothalamus, thalamus, brainstem involved in modulation of nociceptive signaling results in trigeminovascular system activation, cortical-spreading depression-like event, a slowly propagating wave of neuronal and glial cell depolarization and hyperpolarization causing unilateral, pulsating, moderate to severe intensity headache with or without aura.
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Prognosis and risk of recurrence
Acute migraine therapies (triptans, ergotamines, NSAIDs) are ineffective and account for > 50% recurrence of migraine. Approximately 2.2-3.1% of people with episodic migraine progress to chronic migraine at 1-year follow up.
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Guidelines

Key sources

The following summarized guidelines for the management of migraine are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024), the United States Department of Defense (DoD/VA 2024), the Canadian Expert Group on Cannabinoids Use in Chronic Pain (CCP-CEG 2023), the The Scottish Intercollegiate Guidelines Network (SIGN 2023), the American Academy of Neurology ...
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Medical management

Management of acute attacks, analgesics
As per DoD/VA 2024 guidelines:
Offer aspirin/acetaminophen/caffeine for the short-term treatment of migraine.
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Consider offering acetaminophen, aspirin, ibuprofen, or naproxen for the short-term treatment of migraine.
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  • Management of acute attacks (triptans)

  • Management of acute attacks (cannabinoids)

  • Management of acute attacks (antiemetics)

  • Management of acute attacks (CGRP receptor antagonists)

  • Management of acute attacks (other agents)

  • Management of acute attacks (addressing medication overuse)

Nonpharmacologic interventions

Physical therapy
As per DoD/VA 2024 guidelines:
Consider offering physical therapy for the management of migraine headache.
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Consider offering aerobic exercise or progressive strength training for the prevention of migraine headache.
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  • Behavioral interventions

  • Dietary modifications

  • Alternative and complementary therapies

Therapeutic procedures

Botulinum toxin injection
As per DoD/VA 2024 guidelines:
Consider offering onabotulinumtoxinA injection for the prevention of chronic migraine.
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Avoid offering abobotulinumtoxinA or onabotulinumtoxinA injection for the prevention of episodic migraine.
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  • Greater occipital nerve block

  • Supraorbital nerve block

  • Sphenopalatine ganglion block

  • Cervical nerve pulsed radiofrequency

  • Neuromodulation

Surgical interventions

Patent foramen ovale closure: as per DoD/VA 2024 guidelines, avoid offering patent foramen ovale closure for the treatment or prevention of migraine.
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Specific circumstances

Patients with menstrual migraine: as per SIGN 2023 guidelines, offer triptans in patients with acute migraine associated with menstruation.
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  • Pediatric and adolescent patients (diagnosis)

  • Pediatric and adolescent patients (screening for comorbidities)

  • Pediatric and adolescent patients (counseling on prevention)

  • Pediatric and adolescent patients (pharmacologic prophylaxis)

  • Pediatric and adolescent patients (counseling on acute treatment)

  • Pediatric and adolescent patients (management of acute attacks)

  • Pediatric and adolescent patients (monitoring)

Preventative measures

Migraine prophylaxis, beta-blockers: as per DoD/VA 2024 guidelines, consider offering propranolol for the prevention of migraine.
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  • Migraine prophylaxis (anticonvulsants)

  • Migraine prophylaxis (ACEIs/ARBs)

  • Migraine prophylaxis (CGRP receptor antagonists)

  • Migraine prophylaxis (CGRP monoclonal antibodies)

  • Migraine prophylaxis (antidepressants)

  • Migraine prophylaxis (NSAIDs)

  • Migraine prophylaxis (CCBs)

  • Migraine prophylaxis (alpha-agonists)

  • Migraine prophylaxis (ergolines)

  • Migraine prophylaxis (other agents)

  • Migraine prophylaxis (dietary and herbal supplements)