Migraine

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Migraine is a complex neurological disorder that causes severe headache and additional symptoms.

Diagnostic Criteria

ICHD-3 Migraine Diagnostic Criteria

Type	Criteria
Migraine without aura	At least 5 attacks fulfilling criteria B-D Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) Headache has at least two of the following four characteristics: Unilateral location Pulsating quality Moderate or severe pain intensity Aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs) During headache, at least one of the following: Nausea and/or vomiting Photophobia and phonophobia Not better accounted for by another ICHD-3 diagnosis
Migraine with aura	At least 2 attacks fulfilling criteria B and C One or more of the following fully reversible aura symptoms: Visual Sensory Speech and/or language Motor Brainstem Retinal At least three of the following six characteristics: At least one aura symptom spreads gradually over ≥5 minutes Two or more aura symptoms occur in succession Each individual aura symptom lasts 5-60 minutes At least one aura symptom is unilateral At least one aura symptom is positive (e.g., visual flashes rather than loss of vision) The aura is accompanied, or followed within 60 minutes, by headache Not better accounted for by another ICHD-3 diagnosis

Differential Diagnosis

Unilateral photophobia or phonophobia is more common in the Trigeminal Autonomic Cephalalgias than migraine.

Management

Acute Treatment

Acute treatment on more than 2 days a week is associated with medication overuse, which renders prophylactic treatment less effective.

Prophylaxis - Pharmacological

Preventative treatment should be offered in those with 4 or more migraine days a month. Preventative medications must be titrated slowly to an effective or tolerable dose, and continued for 6-8 weeks before effect can be determined. Gradual withdrawal can be considered if effective after 6-12 months.

Table 1: Preventive migraine treatment

Drug class	Drug	Dosage and route	Contraindications	NZ Note
First line medications
Beta blockers	Atenolol	25–100 mg oral twice daily	Asthma, cardiac failure, Raynaud disease, atrioventricular block, depression
	Bisoprolol	5–10 mg oral once daily
	Metoprolol	50–100 mg oral twice daily or 200 mg modified-release oral once daily
	Propranolol	10mg BD starting, 10-20mg titration, trial study dose 120-240mg daily dose. once or twice daily in long-acting formulations		Limited range of formulations limits ease of titration. 160mg MR, 10 and 40mg SR.
Angiotensin II-receptor blocker	Candesartan	2mg starting, 2mg titration, 8–16 mg trial study dose oral per day.	Co-administration of aliskiren
Anticonvulsant	Topiramate	25mg starting, 25mg titration, 25–200 mg trial study dose. Oral once daily	Nephrolithiasis, pregnancy, lactation, glaucoma
Second line medications
Tricyclic antidepressant	Amitriptyline	10-25mg starting, 10-25mg titration, 25-150mg trial study dose at night	Age <6 years, heart failure, co-administration with monoamine oxidase inhibitors and SSRIs, glaucoma
Calcium antagonist	Flunarizine	5–10 mg oral once daily	Parkinsonism, depression	Section 29, not funded
Anticonvulsant	Sodium valproate	600–1,500 mg oral once daily	Liver disease, thrombocytopenia, female and of childbearing potential
Third line medications
Botulinum toxin	OnabotulinumtoxinA	155–195 units to 31–39 sites every 12 weeks	Infection at injection site	Not funded
CGRP monoclonal antibodies	Erenumab	70 or 140 mg subcutaneous once monthly	Hypersensitivity. Not recommended in patients with a history of stroke, subarachnoid haemorrhage, coronary heart disease, inflammatory bowel disease, chronic obstructive pulmonary disease, or impaired wound healing	Not funded
	Fremanezumab	225 mg subcutaneous once monthly or 675 mg subcutaneous once quarterly		Not available
	Galcanezumab	240 mg subcutaneous, then 120 mg subcutaneous once monthly		Not funded
	Eptinezumab	100 or 300 mg intravenous quarterly		Not available
CGRP Gepants	Atogepant	10mg, 30mg, and 60mg all effective vs placebo.		Not funded
	Rimegepant			Not available

Prophylaxis - Other

• Vitamin B2 was effective in a small RCT of 55 patients, dose 400mg daily.
• Magnesium has limited support, 3 positive trials and 1 negative. Typical dose 400-600 daily.
• CoQ10 was effective in a small RCT of 42 patients, dose 100mg tds.
• Feverfew has 4 positive trials and 2 negative trials.
• Aerobic exercise
• Relaxation training
• CBT
• acupuncture

Resources

Migraine diagnosis and management ten steps - Eigenbrodt 2021.pdf - 1.35 MB (f)

Episodic migraine prevention - Silberstein 2012.pdf - 347 KB (f)

Episodic migraine - Loder 2012.pdf - 138 KB (f)

Episodic migraine pediatric - Oskoui 2019.pdf - 327 KB (f)