The first step in the successful management of migraine is to develop a good doctor-patient relationship that results in confidence on the part of the patient. Patients trust physicians more when the physician demonstrates an interest in the patient’s symptoms and overall well-being. Patients appreciate an explanation of their illness by the physician. Good management of headache results from a partnership between doctor and patients.

Patients should be encouraged to keep a headache diary, which should include the frequency, severity, duration, associated symptoms, and medications they are taking. Triggers for each attack, if identifiable, also should be recorded. During each follow-up visit, the diary should be checked and appropriate instruction given.

Physicians should encourage the patient to develop realistic expectations of the treatment of chronic migraine. It is important to explain that migraine is a recurrent disorder and that there is no total cure; the best that can be done is to keep the headaches under some control with abortive as well as preventive medications. Unrealistic expectations usually lead to therapeutic failure. It is natural for the physician to become frustrated when dealing with chronic conditions such as migraine, but it is important the physician not communicate that frustration to the patient. Expressions of encouragement and hope are important therapeutic strategies.

Patient education is extremely important. The clinician may wish to provide the patient with educational materials on headache disorders, which include clinical presentations, triggers, biologic aspects, and myths about headaches.

One of the major myths is the so-called sinus headache as a common cause of recurrent headache. Any headache that is frontal or periorbital, brought on by weather changes, and relieved by analgesic plus decongestants are mistakenly diagnosed as sinus, even in the presence of a long history of episodic headache, family history, and migrainous features. This myth leads to delay in diagnosis, improper and ineffective treatment, and prolongs disability.

Good educational materials should encourage the patient to seek help, taking advantage of modern treatments available for these conditions. It is easier to treat a well-informed patient over the long term; education leads to cost-effective management of headache, avoiding unnecessary doctor visits, emergency room visits, and tests.

Migraine is a disorder of the neurovascular system and is a special response of the human brain to both external and internal triggers. This tendency toward peculiar central nervous system response is probably genetically determined. Migraine patients have a lower threshold for triggering migraine attacks than nonmigraineurs. This threshold is influenced by various factors including female hormones, which account for hormone-related fluctuations in headache, such as in menstrual migraine. Other triggers also must be explained to the patient. Patients
should be given a list of common triggers for migraine so that they can avoid headache episodes. Patients should be taught to look for the triggers that initiate their attacks and to record those triggers in their headache diaries. Common triggers are listed in Table 47-1. Clinicians should teach their patients behavioral modifications to avoid triggers. A simple explanation is all that is necessary in the majority of patients, which can be offered even by the busiest practitioner. The importance of regular eating and sleeping habits should be emphasized. Too much and too little sleep can induce headaches, as can missing a meal.

Patients should scrutinize their diets carefully. Special inquiry into caffeine intake and reducing it may reduce the frequency of migraine. The myths about allergy to food should be dispelled by explaining that dietary activators usually cause chemical reactions rather than an allergic response, and that the chemical reaction influences neurotransmitter functions, resulting in a migraine attack. This understanding of food triggers may circumvent the need for consultation with allergists and various expensive and extensive allergy tests with no beneficial outcome.

If stress is identified as a major factor, it is worthwhile to initiate a stress-management program while proceeding with pharmacologic therapy. Pharmacologic therapy alone, without addressing stress factors, may not be adequate treatment. Thus, behavioral and nonpharmacologic treatment should be administered concurrently with pharmacotherapy. For stress management, any form of relaxation exercise, including biofeedback training, is recommended. Physical exercise, relaxing to many patients, also should be encouraged. Exercise improves sleep, reduces weight, and gives the patient an overall sense of well-being. In the majority of patients, simple instructions from the physician about the broad principles of stress management are sufficient; however, in more complex cases, referral to a clinical psychologist or a behavioral therapist is beneficial.

Psychotherapy and psychiatric counseling may become necessary in patients with significant comorbidities such as depression, anxiety, poor coping abilities, and personality disorders. The practitioner usually has to make an assessment over time concerning the need for psychotherapy. The question of psychotherapy should not be introduced to the patient during the first interview because the patient may get the incorrect impression that the physician views the problem as psychological. On the other hand, if the patient suggests the approach, the clinician should follow through.

Other types of nonpharmacologic treatments may be considered, including physiotherapy, particularly with limited stretching of neck muscles. Massage, short-wave diathermy, and hot packs may be beneficial in those patients who have pericranial and neck muscle tenderness with their migraine attacks, or in those patients with tension-type headache in addition to migraine. If the interictal tension-type headache and muscle spasm can be reduced, it may secondarily reduce the migraine attacks as well.

The patient who fails to respond to conventional treatment may resort to alternative medications. The physician must warn the patient about the lack of information about many of the substances, which are often sold in health food stores. Other techniques such as acupuncture and hypnotherapy have not been evaluated in controlled scientific studies. Therefore, the physician may find it difficult to recommend those to the patient. Although individual patients may benefit from some of these alternative modalities, the rationale for use of alternative medicines varies from unknown to, at best, uncertain.

Nonpharmacologic approaches are indicated for every patient with migraine, whether or not they are candidates for pharmacotherapy. But those who have frequent disabling migraine and those with chronic migraine get best results when pharmacologic approaches are combined with nonpharmacologic approaches.

Treatment of migraine begins with making a diagnosis, explaining it to the patient, and developing a treatment plan that takes into account the frequency of migraine episodes, the severity, the disability they cause, general quality of life of the patient, and coincidental or comorbid conditions. Pharmacotherapy can be acute (abortive) or preventive (prophylactic). Acute treatment attempts to reverse or stop a headache’s progressing once it has started.
Preventive treatment is designed to reduce attack frequency and severity. In the majority of migraine patients, only acute (abortive) treatment of migraine attacks is required. Abortive treatment always should be optimized before prophylaxis is considered. Even in patients treated with prophylactic medication breakthrough migraine attack has to be treated with acute medications. Acute attacks of migraine vary considerably among and within subjects in terms of severity, associated symptoms, disability, and social impact. The efficacy and tolerability of medications used for migraine treatment vary a great deal and, therefore, treatment must be tailored to individual needs of the patient. The same principles hold true for prophylactic treatment.

Specific antimigraine drugs such as ergotamine and triptans are only effective against migraine attacks and not useful in the treatment of episodic tension-type headaches. Accordingly, the treating physician must be aware that patients with frequent migraine attacks have interval headaches, usually tension type. This puts the patient at risk of overuse of antimigraine drugs. Headache diary and proper instructions about distinguishing migraine attacks from other headache is important. Migraine should be treated with antimigraine agents and other headaches should be treated as discussed in Chapter 84. The choice between specific and nonspecific antimigraine medications may depend on the characteristics of migraine attacks; not all attacks in the same patient may require the same drugs. Thus, mild and sometimes moderate attacks may be treated with aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), optionally combined with drugs that promote their absorption such as metoclopramide. Table 47-2 lists the ways of optimizing treatment of acute attacks of migraine.