not changed since 1989, based on evi-

dence from three large studies: Amer-

ican Migraine Study I, 1 American
Migraine Study II, 2 and American
Diagnosing and Managing Migraine Prevention and Prevalence
Study.3 Migraine in the United States is
Migraine Headache more prevalent in Caucasians than in
African Americans, and the lowest
Loretta L. Mueller, DO prevalence in the United States is among
Asian Americans.2 Migraine is gener-
ally more common in people who are in
lower socioeconomic groups.2
Migraine typically begins affecting
individuals when they are in their teens
or twenties, with peak prevalence occur-
ring at approximately age 40 years.2 First
onset of migraine after age 50 years
Headache is one of the chief complaints among patients visiting primary care should raise suspicion of secondary
physicians. Diagnosis begins with exclusion of secondary causes for headache. headache causes. One quarter of adults
More than 90% of patients will have a primary-type headache, so diagnosis can with migraine will experience four or
often be completed without further testing. Although tension-type headaches are more severe attacks per month, each with
the most common kind of headache, patients with this type of headache rarely a mean duration of about 24 hours.2
seek treatment unless occurrence is daily. Migraine, which affects more than
30 million people in the United States, is the most common headache diagnosis Diagnosis of Migraine
for which patients seek treatment. Migraine is a chronic, often inherited condi- Migraine is a diagnosis strongly linked to
tion involving brain hypersensitivity and a lowered threshold for trigeminal-vas- a patient’s medical history. Typical char-
cular activation. Intermittent debilitating attacks are characterized by autonomic, acteristics of migraine headache include
gastrointestinal, and neurologic symptoms. Migraine results in a marked decrease unilateral throbbing pain associated with
in a patient’s quality of life, as measured by physical, mental, and social health- moderate to severe disability, nausea, vom-
related instruments. Accurate assessment of a patient’s disability will guide
iting, phonophobia, photophobia, and
physicians in prescribing appropriate modes of therapy. However, migraine
increased pain with physical exertion.4
remains underdiagnosed, and patients with migraine remain undertreated.
Migraine in children is generally shorter in
A comprehensive treatment approach to migraine may include nonphar-
duration than migraine in adults, with less
macologic measures, as well as abortive and prophylactic medications. Informing
pronounced associated symptoms and
patients about realistic treatment expectations, possible delayed efficacy of med-
possible presentation as cyclic vomiting,
ications, and avoidance of caffeine and overuse of medications is critical for suc-
abdominal symptoms, or paroxysmal ver-
cessful outcomes. Management of migraine is a dynamic process, because
tigo rather than head pain.4
headaches evolve over time and medication tachyphylaxis may occur, necessitating
It is important to note that no iso-
changes in therapy. Pathologic findings in the neck constitute an accepted etiology
lated characteristic is necessary to make
or precipitant for headache. Osteopathic manipulative treatment may reduce
the diagnosis of migraine. The three most
pain input into the trigeminal nucleus caudalis, favorably altering neuromuscular-
predictive characteristics for a migraine
autonomic regulatory mechanisms to reduce discomfort from headache.
diagnosis are disability, nausea, and pho-
J Am Osteopath Assoc. 2007;107(suppl 6):ES10-ES16 tophobia.5 An abbreviated set of diag-
nostic criteria for migraine is available
in a validated screening instrument called
Dr Mueller is an associate professor of family
medicine and director of the University Headache
Center at the University of Medicine and Den-
M igraine is a common condition,
annually affecting 12% of the
United States population, including 18%
ID Migraine.5
Less than a third of patients with
migraine have focal neurologic signs,
tistry of New Jersey-School of Osteopathic
Medicine in Stratford. of women, 6% of men, and 4% of chil- termed auras, just before or during some
Dr Mueller has been principal investigator in dren.1-3 Lifetime prevalence of migraine headaches.4 The diagnosis for these
clinical trials for Merck & Co, Inc; GlaxoSmith
Kline, Vernalis, Ortho-McNeil, and AstraZeneca. in women in the United States exceeds patients is migraine with aura (formerly
She is a national consultant for Merck & Co, Inc, 25%.1-3 The prevalence of migraine has called “classic migraine”), in contrast to
and on speakers bureaus for Merck & Co, Inc, and
GlaxoSmithKline.
Address correspondence to Loretta L.
Mueller, DO, University Headache Center, 42 E This continuing medical education publication is supported by
Laurel Rd, University Doctors Pavilion, Ste 1700,
an educational grant from Purdue Pharma LP.
Stratford, NJ 08084-1354.
E-mail: SOMPhysicians@umdnj.edu

ES10 • JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 Mueller • Diagnosing and Managing Migraine Headache

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 migraine without aura (formerly called
“common migraine”).4 Auras are most
commonly visual and less commonly
sensory or motor in nature. Migraines
associated with motor auras are called
hemiplegic migraines and may occur on a
hereditary basis within families and a
sporadic basis among individuals.4 Trip-
tans are contraindicated for patients with
hemiplegic migraine because of a lack
of adequate testing of these medications
in this small population.
Migraine is often mistaken for sinus
or tension headache. Migraine is con-
fused with sinus headaches because the
autonomic symptoms of migraine
include nasal stuffiness or discharge,
occurring in 87% of patients with
migraine.6 In addition, the headache in
these patients may be located above the
sinuses.6 Migraine often is confused with
tension headache because 75% of patients
with migraine have neck pain during or
immediately before or after a migraine.7
The diagnosis of migraine is based
on criteria developed by the International
Headache Society in 1988 and revised
by the society in 2004—the International
Classification of Headache Disorders II
(ICHD II).4 Similar to the Diagnostic and
Statistical Manual of Mental Disorders
(DSM IV) used in psychiatric evalua-
tions, the ICHD II requires that patients’
headaches must have certain character-
istics for each kind of diagnosis (Figures
1 and 2). Headaches are categorized by
primary or secondary headaches, with
four broad groups of primary headaches,
including migraine, tension, cluster, and
miscellaneous headaches, and 10 broad
groups of secondary headaches
(Figure 2).4
Although necessary for medical
research, the ICHD II criteria4 may be
cumbersome for use by physicians in the
primary care setting. Nevertheless, the
criteria do offer a process for organizing
a differential diagnosis; if patients have
the symptoms listed in the criteria, physi-
cians are more comfortable that the
patient truly has that primary headache
diagnosis and is less likely to have a brain
tumor or other grave condition.
Any abnormalities in a patient’s
medical history or physical examination
suggesting secondary headache must be
carefully evaluated before making a pri-
Mueller • Diagnosing and Managing Migraine Headache
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Diagnostic Criteria for
Migraine Without Aura
䡵 A. At least five headache attacks
fulfilling criteria B through D
䡵 B. Headache attacks lasting
4 to 72 hours (untreated or
unsuccessfully treated)
䡵 C. Headache has at least two of
the following characteristics:
䡺 Unilateral location
䡺 Pulsating quality
䡺 Moderate or severe pain
intensity
䡺 Aggravation by, or causing
avoidance of, routine physical
activity (eg, walking or climbing
stairs)
䡵 D. During headache, at least one
of the following characteristics:
䡺 Nausea and/or vomiting
䡺 Photophobia and/or
phonophobia
䡵 E. Headache cannot be
attributed to another disorder
Figure 1. The International Classification
of Headache Disorders II (ICHD-II) criteria for
migraine without aura. (Source: Headache
Classification Subcommittee of the Interna-
tional Headache Society. The international
classification of headache disorders. Cepha-
lalgia. 2004;24(suppl 1):14-160.)
mary headache diagnosis. However, rec-
ommendations by the US Headache
Consortium8 state that neuroimaging is
generally not necessary in adult patients
presenting with typical migraine, normal
findings on neurologic examination, and
no recent change in headache character-
istics.9 These recommendations are based
on data indicating that only 0.18% of this
patient group show a clinically signifi-
cant intracranial pathologic lesion on
neuroimaging.9
Triggers of Migraine
Migraine is believed to be an inherited
condition of cortical hyperexcitability.10
Some patients with migraine are able to
identify headache triggers. Triggers may
be inconsistent or additive and are not
JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES11
specific to migraine. For example, menses
is a trigger for 60% of female migraineurs
and is also a trigger for tension-type
headache.11 Stress or “let-down” after a
stressful event, change in sleep or meal
schedules, and such environmental fac-
tors as loud noise, odors, or flickering
lights may also precipitate migraine
headache.11
Approximately a quarter of patients
with migraine recognize certain food as
migraine triggers.12 Such triggers include
monosodium glutamate (also known
as hydrolyzed yeast extract, natural fla-
voring, hydrolyzed vegetable protein),
often found in soups and Chinese food.12
Nitrites (a preservative found in lunch
meats and hot dogs), tyramines (found in
wines and such aged foods as cheeses),
and phenylethylamine (found in choco-
late, garlic, nuts, raw onions, and seeds)
are other potential migraine triggers.12
Alcohol of any kind, artificial sweeteners,
citrus fruits, pickled products, and vine-
gars are additional likely triggers.12 It
should be noted that not all patients have
these food triggers, so a diet totally elim-
inating these items is not warranted in all
migraineurs.
Daily consumption of caffeine can
lead to caffeine withdrawal headaches
or rebound headaches interfering with
or negating the effects of migraine pre-
ventive medications. Daily caffeine con-
sumption is much greater than many
people expect, with a typical cup (8 oz) of
drip coffee containing about 135 mg of
caffeine.13 Patients should be advised
that caffeine is used in combination with
many over-the-counter (OTC) pain med-
ications because it enhances analgesia.14,15
Caffeine has a half-life of up to 9.5 hours;
and the body transforms it into more
than 25 metabolites.14
Overuse of caffeine is a risk factor for
progression of occasional migraine to a
chronic daily pattern. Additional con-
siderations for such a progression include
acute medication overuse, depression,
obesity, sleep disorders, and stressful life
events.16
Head trauma may cause or exacer-
bate headaches. Based on ICHD II cri-
teria,4 new onset of headaches within
7 days of head trauma is diagnosed as
posttraumatic headache, while continued
headache after 3 months is termed
 Figure 2. The International Classification of
Headache Disorders II (ICHD II) outline of pri-
mary headache disorders and secondary
headache disorders, developed by the Inter-
national Headache Society in 1988 and revised
by the society in 2004. (Source: Headache
Classification Subcommittee of the Interna-
tional Headache Society. The international
classification of headache disorders. Cepha-
lalgia. 2004;24(suppl 1):14-160.)
chronic posttraumatic headache. Even
mild head trauma without loss of con-
sciousness or objective findings can cause
new onset or exacerbation of headaches,
necessitating long-term management.4
The proposed neurophysiologic
basis for cervicogenic headache is nocio-
ceptive input from trigeminal and cer-
vical (C1-C3) afferent neurons converging
on second-order neurons in the
trigeminocervical nucleus.17 In addition,
several recent anatomic discoveries iden-
tify direct neuronal connections between
extracranial structures and the dura
mater.18 Hack et al19 found a neuronal
connection between the rectus capitis
posterior minor muscle and dorsal spinal
dura mater at the atlanto-occipital junc-
tion, which appears to restrict dural
movement toward the spinal cord.
Abnormalities in the cervical spine, such
as muscular spasm, may transmit forces
to the pain-sensitive dura mater.
Theoretically, alleviating accessible
causes of pain through such modalities as
osteopathic manipulative treatment
(OMT) should increase a patient’s
headache thresholds. However, because
of a lack of controlled studies on OMT
and other modalities, biofeedback is the
only nonpharmacologic therapy for
migraine that is considered to be “evi-
dence-based” by the US Headache Con-
sortium.8
Pharmacologic Management
of Migraine
Abortive Medications
More than 90% of patients with migraine
have disability with their attacks, and
half these patients require bed rest.20
Despite this high level of disability, less
than 60% of patients with migraine have
their headache diagnosed as such by a
physician.20 Thus, many patients are not
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Outline of International Classification
of Headache Disorders II
䡵 Primary Headache Disorders
䡺 1. Migraine
— Migraine without aura
— Migraine with aura
— Childhood periodic syndromes that
are precursors of migraine
— Retinal migraine
— Complications of migraine
— Probable migraine
䡺 2. Tension-type headache
— Infrequent episodic tension-type
— Frequent episodic tension-type
— Chronic tension-type
— Probable tension-type
䡺 3. Cluster headache and other
trigeminal autonomic cephalgia
— Cluster headache
— Paroxysmal hemicrania
— Short-lasting unilateral
neuralgiform headache attacks with
conjunctival injection and tearing
— Probable trigeminal autonomic
cephalgia
䡺 4. Other primary headaches
— Primary stabbing headache
— Primary cough headache
— Primary exertional headache
— Primary headache associated with
sexual activity
— Hypnic headache
— Primary thunderclap headache
— Hemicrania continua
— New daily persistent headache
adequately treated with abortive or pro-
phylactic medications for migraine. A
major obstacle in diagnosing headache in
a primary care setting is time constraint.
An average office visit by a patient to a
primary care physician lasts 9 minutes
and usually addresses multiple com-
plaints.2 Scheduling additional visits
specifically to address the headache com-
plaint and having patients keep diaries of
headache frequency, severity, and med-
ications may help overcome obstacles to
proper diagnosis and treatment.
Patients are usually not adept at ini-
tiating accurate descriptions of disability
experienced during migraine attacks, and
physicians may not accurately assess
migraine-related disability of their
patients, many of whom may be healthy
young individuals between headache
attacks. In light of these problems, a clin-
ically useful, validated instrument for dis-
Mueller • Diagnosing and Managing Migraine Headache
䡵 Secondary Headache Disorders
䡺 5. Headache attributed to head and
neck trauma
䡺 6. Headache attributed to cranial or
cervical vascular disorders
䡺 7. Headache attributed to
nonvascular intracranial disorder
䡺 8. Headache atributed to substance
or its withdrawal
䡺 9. Headache attributed to infection
䡺 10. Headache attributed to
disturbance of homeostasis
䡺 11. Headache or facial pain
attributed to disorder of cranium,
neck, eyes, ears, nose, sinuses, teeth,
mouth, or other facial or cranial
structures
䡺 12. Headache attributed to
psychiatric disorders
䡺 13. Cranial neuralgias, central and
primary facial pain and other
headaches
䡺 14. Other headache, cranial
neuralgia, central or primary facial
pain
ability assessment is the Migraine Dis-
ability Assessment (MIDAS) tool,21 which
can be used to assess the number of work
or school days lost during a 3-month
period due to migraine. Studies show
that healthcare providers are more likely
to treat patients with effective, migraine-
specific therapeutic modalities if they are
aware of the patients’ migraine disabili-
ties.22,23 The Disability in Strategies of
Care (DISC) trial22 confirmed that patients
with moderate to severe migraine-caused
disability are more likely to respond to
high-end modes of therapy. In the DISC
trial, 75% of patients had a failed response
to high-dose aspirin (800-1000 mg/d) and
metoclopramide (10 mg/d) therapy,
requiring zolmitriptan (2.5 mg/d) as effec-
tive high-end therapy.
The US Headache Consortium rec-
ommends serotonin 5HT1B/D agonists
(ie, triptans) as first-line therapy in a strat-
 ified-care approach for patients with
migraine who experience moderate to
severe disability (Figure 3).23 Seven trip-
tans are available for migraine, all in tablet
formulation.23 Two of these triptans (riza-
triptan, zolmitriptan) are available as oral
wafers that may be taken without water;
two (sumatriptan, zolmitriptan) are avail-
able as nasal sprays; and one (suma-
triptan) is available in a subcutaneous
formulation.23 Headache relief with trip-
tans is not pathognomonic to migraine;
migraine, tension-type, and secondary
headaches may all respond to these
drugs.24 Conversely, not all migraines
respond to triptans.24
Triptans have the same contraindi-
cations in patients with known or sus-
pected ischemic cardiac, cerebrovascular,
peripheral vascular, or uncontrolled
hypertensive disease.25 However, the
Triptan Cardiovascular Safety Expert
Panel concluded that chest symptoms
occurring with triptan use are generally
not serious or ischemic; the incidence of
serious cardiovascular events with triptan
use appears to be extremely low; and the
cardiovascular risk-benefit profile of trip-
tans favors their use in the absence of
contraindications.25 One type of triptan
should not be combined with another
type or with a vasoconstrictor within
24 hours of administration. Rizatriptan,
sumatriptan, and zomitriptan should not
be used within 2 weeks of administration
of a monoamine oxidase (MAO) inhibitor;
rizatriptan should be dosed at 5 mg per
dose for patients using propranolol
hydrochloride; and eletriptan should not
be used within 3 days of the use of strong
cytochrome P4503A inhibitors, such as
clarithromycin.
Labels on all triptans carry a cau-
tionary statement noting that these drugs
may cause the “serotonin syndrome”
when used in combination with other
serotonergic drugs such as serotonin
reuptake inhibitors (SSRIs, including the
antidepressant fluoxetine hydrochlo-
ride).26 Symptoms of serotonin syndrome
may include autonomic hyperactivity
such as tremor, diarrhea, hypertension
and tachycardia. Neuromuscular abnor-
malities or mental status changes such
as rigidity, hyperreflexia, hyperthermia,
anxiety, or akathisia are additional symp-
toms. Although all triptans have docu-
Mueller • Diagnosing and Managing Migraine Headache
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Treatment Considerations
PROPHYLACTIC MEDICATION
䡵 ␤-Blockers
䡺 Good choice with hypertension,
angina, anxiety
䡺 Caution with asthma, depression,
bradycardia,hypotension, type 1
diabetes mellitus, Raynaud
disease, congestive heart failure,
prolonged aura, athlete
䡵 Tricyclic Antidepressants
䡺 Good choice with insomnia,
depression, fibromyalgia
䡺 Caution with heart block, bipolar
disorder, epilepsy, urinary
retention, hypotension,
glaucoma
䡵 Antiepileptic Drugs
䡺 Good choice with epilepsy,
bipolar disorder, anxiety, obesity
(topiramate)
䡺 Caution with liver disease,
bleeding disorder, obesity
(valproate), nephrolithiasis
(topiramate)
䡵 Calcium Channel Blockers
䡺 Good choice with hypertension,
angina, prolonged aura
䡺 Caution with heart block,
hypotension, constipation
Figure 3. Prophylactic medication consider-
ations for patients with migraine, as recom-
mended by the United States Headache Con-
sortium. (Source: Silberstein SD. Practice
parameter: evidence-based guidelines for
migraine headache (an evidence-based
review): report of the Quality Standards Sub-
committee of the American Academy of Neu-
rology [published erratum appears in Neu-
rology. 2000;56:142]. Neurology. 2000;55:
754-762.)
mented efficacy for migraine with and
without aura (including menstrual
migraine), naratriptan and frovatriptan
generally have slower onset of action as
demonstrated by 2 hours’ pain relief data.
Interpatient variability also exists
for triptan efficacy, with different patients
responding differently to particular trip-
tans, and some patients requiring tran-
JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES13
sition from one triptan to another to
maintain efficacy.23 Assessment of effi-
cacy of triptans and other abortive med-
ications should be repeated at each
patient visit, with several questions asked
of patients and various target endpoints
addressed (Figure 4).
Alternative abortive medications to
triptans include ergots and their syn-
thetic derivative, dihydroergotamine;
butalbital-containing analgesics or other
analgesic combinations; isometheptene
mucate combination; nonsteroidal anti-
inflammatory drugs (NSAIDs); and opi-
oids.23 Administration of butalbital-con-
taining products is controversial because
there are no placebo-controlled trials sup-
porting their efficacy for migraine. In
addition, the potential exists for butal-
bital overuse resulting in rebound
headaches, and some patients may use
butalbital-containing products to treat
underlying comorbid anxiety.23 Opioid
therapy is also controversial, with sev-
eral studies reporting activation of prono-
ciceptive mechanisms with long-term
use of opioids.27,28
“Rescue” treatment options when
first-line agents fail in an outpatient or
emergency department setting include
the following: dihydroergotamine, dival-
proex sodium,29 droperidol,30 intranasal
lidocaine,31 ketorolac, magnesium sul-
fate,32 opioids, parenteral sumatriptan,
prochlorperazine, propofol, 33 and
steroids. All of these medications except
sumatriptan and dihydroergotamine are
used off-label for migraine.
Abortive polytherapy is an option
when single agents do not provide ade-
quate relief for patients with migraine.
An NSAID and/or a gastrokinetic drug
(eg, metoclopramide) may be used in
addition to a triptan.34
Researchers have found that cuta-
neous allodynia (a condition in which
such nonnoxious stimuli as mechanical
pressure and thermal changes cause skin
pain) develops in nearly 80% of patients
with migraine.35 Studies indicate that
cutaneous allodynia is a marker for cen-
tral sensitization and abortive medica-
tions are less likely to produce complete
pain relief after this phenomenon
develops.35
Providing abortive treatment during
the early mild phase of migraine results

Assessment of Abortive Medication Efficacy
Factor to Assess
䡵 Rapidity of relief
䡵 Partial vs total pain relief
䡵 Relief of associated symptoms
䡵 Return to normal function
䡵 Headache recurrence
䡵 Consistency of response
䡵 Adverse effects
䡵 Preference/convenience
of formulation
䡵 Cost
Figure 4. Factors to assess and target endpoints for assessment of efficacy of abortive med-
ications in treatment of patients with migraine.
in higher pain-free rates among
patients.35 However, for patients with
frequent headaches who consistently
require treatment more than 2 days per
week, prophylactic medication may be
needed to reduce headache frequency.
The potential for headache rebound
exists with frequent use of most abortive
medications, including butalbital-com-
bination products, caffeine-containing
products, and triptans.23
Prophylactic Medications
Generally, prophylactic medications
(Figure 3) are taken daily to reduce
headache frequency, decrease headache
intensity, and/or allow for improved
abortive management of migraine.
However, more subtle improvements
in quality of life may warrant continu-
ation of prophylactic therapy, even if a
high level of headache reduction is not
achieved. Serial MIDAS tests can mon-
itor improvements for such measures
as lost work or school days and loss of
productivity related to home chores or
social functions.21 More than one pro-
phylactic medication may be used in
combination when only a partial
response is achieved with one drug and
when that drug’s dosage cannot be
increased because of maximal dose or
drug intolerance. Prophylactic modes
of therapy may be used intermittently
for headaches occurring at predictable
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Target Endpoint
Meaningful onset within 1 h
Total relief within 2 h
No nausea, vomiting, photophobia,
phonophobia
2 h without sedation
Total relief with 1 dose of abortive
medication
Relief for every headache
None or minimal
Ease of use, taste, convenience
Weigh cost against efficacy and function
times, such as during menses, exercise,
or sexual activity.23
Physicians should keep in mind that
prophylactic medications are not a cure
for headache, and abortive therapy will
remain necessary for breakthrough
attacks. In addition, patient education
about medication use is important for
compliance.
No prophylactic medication was
originally developed to treat patients
with migraine, and only four medica-
tions have US Food and Drug Adminis-
tration (FDA) indication for migraine:
divalproex sodium, propranolol, timolol
maleate, and topiramate. Major classes
of prophylactic medications for migraine
include antiepileptics, ␤-blockers, cal-
cium-channel blockers, and tricyclic
antidepressants (Figure 3).23 The exact
physiologic mechanisms of these varied
drugs are not known, but the mecha-
nisms are believed to involve suppression
of central hyperexcitability and/or
enhancement of antinociceptive path-
ways.10
Comorbidities (eg, angina, depres-
sion, epilepsy) generally will influence
prescribing considerations for prophy-
lactic medications (Figure 3). The
US Headache Consortium has published
evidence-based guidelines for selecting
a prophylactic medication for patients
with migraine.23 There are conflicting
reports regarding the efficacy of
Mueller • Diagnosing and Managing Migraine Headache
botulinum toxin A for migraine or chronic
daily headache prophylaxis, with most
studies not achieving primary endpoint
efficacy.36
For patients with infrequent
migraines and those who are reluctant
or unable to use prescription prophy-
lactic medications, alternative agents may
be considered. Dietary supplements that
may be effective for migraine preven-
tion, based on results of placebo-con-
trolled trials, include butterbur root (Pet-
asites hybridus), coenzyme Q10, feverfew,
magnesium, melatonin, and riboflavin
(vitamin B2).37,38 Many combination prod-
ucts are available, such as MigreLief
(feverfew, magnesium, riboflavin) and
Migravent (butterbur root, feverfew,
magnesium, riboflavin; Vita Sciences,
Airmont, NY).
The following anecdotal case pre-
sentation describes a typical patient
whose case illustrates the diagnosis and
management of migraine.
Case Presentation
Cheryl is a 44-year-old woman with peri-
menopausal symptoms of hot flashes inter-
rupting sleep. She is seen by her physician
because of an exacerbation of headaches that
are unilateral, hemicranial, throbbing, and
associated with nausea and photophobia. At
times she must lie in a dark quiet room to
try to help ease her headache pain. She denies
having associated neurologic symptoms such
as vision loss, but she says that she often
yawns for several hours before headaches,
and she has some nasal congestion and neck
ache during the pain phase.
Cheryl’s headaches started at age
14 years, typically occurring only during her
menses and persisting for 1 day. She now
complains of a gradual increase in headache
frequency and duration during the previous
2 years, with her typical “bad” headaches
(ie, migraine without aura) occurring both
during menses (lasting 4 days) and outside of
menses (two attacks lasting 1 day each).
Sumatriptan succinate tablets (100 mg/d) no
longer provide her with adequate relief.
On further questioning, Cheryl admits to
milder headaches occurring on a daily basis for
at least the entire previous year. She says she
manages those headaches daily with six OTC
combination analgesics containing caffeine,
accounting for 390 mg of caffeine
(65 mg/tablet) per day. She had not initially
 noted this analgesic use on her medication
list because she believed she could control these
milder headaches on her own. She also admits
to drinking two cups of coffee daily (20 oz
each), accounting for approximately 675 mg
of additional caffeine (135 mg/8 oz)13 per day.
Cheryl reports that all previous preven-
tive treatments had failed, including dival-
proex sodium (1000 mg/d for 3 wk), topira-
mate (25 mg/d for 2 mo), and verapamil
(240 mg/d for 1 mo). She notes that she could
not tolerate propranolol hydrochloride
(60 mg/d) because it made her too tired.
Management of Cheryl’s Headaches
䡵 Make the Proper Diagnosis—Take
a detailed headache history of the patient,
including all prescription and OTC med-
ications used and the frequency of their
use.
Cheryl’s headache diagnosis is migraine
without aura, in addition to probable medi-
cation overuse headache. She has a long his-
tory of typical migraines. However, the char-
acter of her headaches has changed. They have
become more frequent and more difficult to
manage, requiring additional medications.
These changes may indicate the need for fur-
ther testing, such as brain MRI, though there
are certain known reasons for escalation of
Cheryl’s headaches.
She is overusing caffeine and analgesics,
substances that may cause, worsen, or main-
tain her daily headache pattern. She is also
perimenopausal, with hormonal fluctuations
and sleep disturbance. Thus, it may be rea-
sonable to withdraw the overused agents with
close follow-up before conducting further
testing.
䡵 Educate the Patient About Non-
pharmacologic Management—Cheryl
should understand that her diagnosis is
migraine, that there are no objective markers
for this disorder, and that it is usually inher-
ited, chronic, and biochemical in nature.
There is no single definitive cause
of migraine or definitive treatment for
patients with migraine. However, the
disorder can be successfully managed.
It is important for the patient to stay reg-
imented in her daily schedule, including
meals and sleep. Fluid intake should be
maintained, because dehydration is a
trigger for migraine. Any identified food
triggers for migraine should be avoided,
though food may not consistently trigger
Mueller • Diagnosing and Managing Migraine Headache
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headaches and may be additive with
other stimuli.
The patient should be especially
careful to avoid migraine triggers during
her most vulnerable time for headaches
(ie, during menses). Regular exercise may
have beneficial effects on headaches.
Relaxation activities, including biofeed-
back training, listening to relaxation
tapes, and performing yoga, may also
be beneficial. Furthermore, OMT for par-
avertebral cervical spasm associated with
headaches may be beneficial—though
some patients have cutaneous allodynia
during acute migraine and may prefer
not to be touched at such times.
䡵 Educate the Patient About Pharma-
cologic Management—Use of all anal-
gesics and caffeine was terminated. Cheryl
was warned that she would probably have
more intense headaches while withdrawing
from these substances and that any prescribed
abortive medications may not work as effec-
tively as a caffeine product for the next few
weeks.
Removal of offending agents alone may
markedly improve headaches, but most
patients still require prophylactic therapy.
Treatment with prophylactic medications was
initiated immediately, and Cheryl was made
aware that medication doses are started low
and gradually increased, depending on
observed efficacy and adverse effects. It may
take 3 months for prophylactic medications to
achieve complete benefit at the full therapeutic
doses. In the past, this patient did not achieve
effective doses of prophylactic medications or
did not use these medications long enough. In
addition, she had been overusing caffeine and
abortive medications during prophylactic
medication trials, rendering the medications
ineffective.
䡵 Initiate Treatment—Cheryl was edu-
cated; weaned off caffeine and an OTC pro-
prietary acetaminophen-acetylsalicylic acid
(ASA)-caffeine formulation; started on an
alternative triptan for first-line acute treat-
ment; and given a second-line abortive med-
ication (a phenothiazine) for nausea and/or
rescue pain when the triptan did not provide
complete relief.
Rescue therapy is often sedating,
but the goal of rescue therapy is allevia-
tion of pain and associated symptoms
rather than restoring full function.
JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES15
Cheryl was encouraged to not take any OTC
medications for her daily milder headaches,
but she was given an NSAID as needed for up
to 2 days per week. A daily regimen of low-
dose amitriptyline (10 mg/d for 1 wk; then
20 mg/d) at bedtime was started for headache
prevention; this medication also helped Cheryl
sleep. She was provided with detailed written
instructions on her treatment and a diary to
keep track of her headache frequency, severity,
and medications.
䡵 Have the Patient Follow Up—
Headaches change with time, and sec-
ondary headaches may develop in
patients who have had life-long
headaches. In addition, abortive and pro-
phylactic medications need to be contin-
ually assessed and adjusted to achieve
maximal benefit. Physicians should
review headache diaries, any medication
adverse effects, and any changes in med-
ical condition that may warrant changes
in therapy. Generally, prophylactic med-
ications are continued for approximately
6 months if a beneficial response is
achieved, then attempts are made to
wean the patient away from the medi-
cations.
Prophylactic medications may be
stopped with continued observed bene-
fits, or headaches may worsen. If
headaches worsen, the lowest dose that
adequately controls headache should be
maintained.
Cheryl had severe headaches during the
first week she was off caffeine and the
acetaminophen-ASA-caffeine formulation.
She then noticed a lessening of headache inten-
sity, with some headache-free days by the
third week of therapy. At her next visit,
1 month later, amitriptyline was increased
to 40 mg/d. Two months after her second
visit, Cheryl had only one migraine with
menses per month. The use of her triptan
during these episodes provided complete pain
relief within 2 hours. Recurrence of headache
24 hours later was again relieved with her
triptan. After 2 months, Cheryl rarely had
mild tension-type headaches and did not
require abortive treatment for such headaches.
Comment
Migraine is the most common type of
headache seen in primary care. Yet,
migraine is often not properly diagnosed,
and patients with migraine are often
 inadequately treated because of physi-
cian time constraints, lack of physician
understanding of migraine-related dis-
abilities, incorrect patient self-diagnosis,
and/or incomplete patient medication
history.
Successful management of migraine
requires intensive patient education and
thorough physician knowledge about
available treatment options and strate-
gies. These treatment options and strate-
gies include stratified care with a
migraine-specific abortive medication for
patients with moderate to severe dis-
ability; early intervention with an
abortive medication before central sen-
sitization occurs; and the use of a pro-
phylactic medication to reduce headache
frequency, severity, and risk for rebound.
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Editor’s Note
Physicians are advised to check the full
prescribing information for all the medications
discussed in this article and keep current
with all FDA advisories and warnings.