An overview of the diagnosis and pharmacologic treatment of migraine.

Migraine, an episodic headache disorder, is one of the most common complaints encountered by primary-care physicians and neurologists. Nevertheless, it remains underdiagnosed and undertreated. Rational migraine treatment necessitates an accurate diagnosis, identification and removal of potential triggering factors, and, frequently, pharmacologic intervention. Effective management also includes establishing realistic expectations, patient reassurance, and education. The choice of medication (abortive, symptomatic) for an acute attack depends on such factors as the severity of the attack, presence or absence of vomiting, time of onset to peak pain, rate of bioavailability of the drug, comorbid medical conditions, and side-effect profile. Effective agents for acute attacks include simple or combination analgesics, nonsteroidal anti-inflammatory drugs, ergot derivatives, selective serotonin agonists, and antiemetics. Opioid analgesics are unnecessary for most patients. The choice of preventive (prophylactic, interval) medication depends primarily on comorbid medical conditions and side-effect profile. Useful preventive agents include beta-adrenergic blockers, calcium channel blockers, tricyclic antidepressants, anticonvulsant medications, and serotonin antagonists.