Migraine Medications

Migraine is a primary headache disorder commonly associated with nausea/vomiting, sensitivities to light/sound/smell, and auras signaling that a headache may soon occur. Approximately 1 in 7 American adults suffer from migraines, and the economic costs in 2016 were estimated to be $36 billion. This figure includes factors such as medical costs and loss of productivity (i.e., disability). Additionally, the total amount of annual emergency department visits for migraines is approximately 1.2 million, and many of these visits can be avoidable. In the international classification of headache disorders 3rd Edition (ICHD-3), migraines may be diagnosed with aura or without (see below for diagnostic criteria). There is also a definition of chronic migraine. For migraines without aura, diagnostic criteria include: 1. 5+ attacks fulfilling the other criteria. 2. Headache attacks that last from 4 to 72 hours (untreated or unsuccessfully treated). 3. Headache consisting of at least 2 of the following characteristics: unilateral location, pulsating quality, moderate/severe pain intensity, and aggravation by or causing avoidance of routine physical activity (i.e., walking or climbing stairs). 4. During the headache, the presence of at least one of the following: nausea/vomiting, photophobia/phonophobia. 5. Not better accounted for with another ICHD-3 diagnosis. For migraines with aura, diagnostic criteria include: 1. Two or more attacks fulfilling the other criteria. 2. At least one of the following completely reversible symptoms of aura: visual, sensory, motor, speech or language, brainstem, retinal. 3. At a minimum of three of the following six characteristics: 1+ one aura symptoms spread gradually over greater than equal to 5 minutes, 2+ aura symptoms occur in succession, each aura symptom lasts 5-60 minutes, 1+ aura symptom is unilateral, 1+ aura symptom is positive, the aura is accompanied or followed within 60 minutes by the headache. 4. Not better accounted for with another ICHD-3 diagnosis. For chronic migraine, diagnostic criteria include: 1. Headache (migraine-like or tension-type-like) on greater than or equal to 15 days/month for greater than three months and also fulfilling criteria B and C. 2. Occurring in a patient who has experienced at least five attacks fulfilling criteria B through D for migraine presenting without aura and/or criteria B and C for migraine that presents with aura. 3. Occurs greater than or equal to 8 days/month for greater than three months, fulfilling any of the following. 4. Criteria C and D for migraine without aura. 5. Criteria B and C for migraine with aura. 6. Believed by the patient to be migraine at the point of onset and relieved by a triptan or ergot derivative. 7. Not better accounted for with another ICHD-3 diagnosis. This activity will cover the available classes of migraine treatments commonly in use and have significant evidence for use. The two categories will be abortive and preventive treatments. For abortive therapies, they are usually more effective when taken early in the course of the headache, and in a larger dose rather than repeated small doses. Of note, many abortive oral agents may be ineffective because of poor absorption secondary to migraine-induced gastric stasis.