Migraine Headache Treatment Protocols: One Size Does Not Fit All

Robert P. Cowan, MD


April 17, 2019

Editorial Collaboration

Medscape &

The story goes something like this: A group of people are brought into a room that is completely dark and are asked to identify the object in the room. They begin to scatter, arms outstretched feeling for something. The first calls out, "I have it! It is large, rough-surfaced, dry, and round, very tall. The object is a tree!" But then another chimes in, "No, I have it. It is much smaller than a tree and it is flexible, round moving through space. It is an enormous snake!" And then a third, "You're both wrong. I am standing beneath it and it is a low-hanging ceiling, perhaps the bottom of an enormous balloon!"

There are many variations to this story, but the lesson is always the same: Without the whole picture, it is almost impossible to make the right call. Often, headache specialists are asked, "What is your 'go-to' treatment for migraine? What is your 'first-line' preventive? What is the 'best' rescue medicine? Those questions are like asking us to describe the elephant in the darkened room. Without knowing the whole picture—in this case, the whole headache history—it is impossible to recommend the ideal treatment. Treatment protocols for migraine headache are specific to each patient. In this instance, one size does not fit all.

Two Patients: Same Diagnosis, Different Treatment Goals

Consider two patients recently seen on the same day. Coincidentally, both were named Kathy. Both came to their appointment with a diagnosis of migraine headache, occurring about twice, sometimes 3 days per week. Both were interested in a better treatment when a headache came on, and if possible, something to help prevent headaches. Should they both get the same treatment? Same diagnosis, so why not? They are not the same person.

Kathy #1 was 26, thin, and a daily runner, with one child and hoping for a second. Kathy #2 was 45 and a high-level executive who worked long hours, and "hadn't slept well in years." Kathy #1 described headaches that came on quickly, peaking in intensity within 30 minutes, associated with nausea and lasting around 4 hours or until she went to sleep or vomited. Kathy #2 described headaches that were always present but were only disabling 2-3 days per week and, on those days, the arrival of the severe headache was gradual, developing over hours. The more challenging symptoms for her were bright lights and loud sounds, not nausea.

Kathy #1 wanted treatment options that would be safe if she became pregnant and would allow her to care for her children. Kathy #2 sought treatment options that would let her get through the day.

Two women with the same diagnosis, but very different presentations and very different goals. This is why providers need to combine a little bit of art along with the science. There is no one treatment plan that would meet the needs of both patients.

Fortunately, there are many treatment options available to the well-informed practitioner (and patient). But the first step is to identify the patient's needs: Kathy #1 wants medication that will act quickly to abort a headache, but not "hang her over" and that would be safe should she become pregnant. Kathy #2 was hoping for something she could take (or do) that would keep her headaches under control, and keep them from returning often.

Patient-Specific Treatment Plans

When developing treatment plans for their patients, the standard strategy among most headache specialists is to incorporate elements from four categories of treatment options. The first, acute treatments, are those used at the onset of a headache. Some have a very quick onset and a relatively short duration of action (good for someone who doesn't want to feel "hung over," but not so good for someone who isn't sure exactly when her headache is going to cross the line into something terrible). Other acute medicines don't act as quickly but last much longer. Some are very powerful but can be cause gastric upset, chest tightness, or fatigue. Increasingly, non-medicine alternatives for treatment, such as devices and behavioral interventions, are finding a place in some acute treatment strategies.

The second category is known as the "preventives”: (sometimes called "preventatives" or "prophylaxis"). There are many choices with effectiveness that varies from patient to patient. As yet, we have no perfect preventive that works 100% in every patient but, clearly, some are a better fit for a given patient than others. For example, Kathy #1 is thin and probably wouldn't want a preventive that causes weight loss. Kathy #2 has trouble sleeping, so she might benefit from one that has sleepiness as a side effect and is taken at bedtime. There are many other factors (eg, cost, preferred delivery system, dosing preferences, potential medication interactions, allergies, coexisting medical problems) that go into the decision of prevention, which should be a joint decision between the provider and the patient. The options are not limited to medications, but may also include non-pharmacologic interventions, such as mindfulness training, pain psychology, acupuncture, and physical therapy.

The third category is lifestyle changes. Most patients benefit from learning about the importance of regular sleep, eating, and exercise schedules—but not every patient will get the same recipe, of course.

Category four, the rescue treatments, is important because most patients want to know what to do when acute treatments fail. Again, this will be patient-specific. For some, it may be an additional medicine to be used only for rescue; for others, it might be a standing order for an intravenous infusion at a nearby urgent care facility, emergency department, or infusion center.

In summary, migraine headache is not an infection where the correct antibiotic will effectively treat a specific bacterium. The more the provider knows about the patient's headaches, other medical issues, and specific goals, the better able they will be to help craft the "best" treatment plan and to modify it over time. In other words, the best treatment strategy is the one the patient and provider work out together through open and honest dialogue and exploration of all the options.

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