Appendix 2 Consensus-based general principles of adult migraine management 17

• Establish a diagnosis.
• Assess the headache burden or disability:
    ○ Treatment choice depends on the frequency and severity of attacks,
    ○ the presence and degree of temporary disability,
    ○ impact on the patient’s quality of life, and
    ○ associated symptoms such as nausea and vomiting.
• Educate migraine sufferers and their families about their condition and its treatment.
• Discuss the rationale for a particular treatment, how to use it, and what adverse events are likely.
• Encourage the patient to identify and avoid triggers.
• Establish realistic patient expectations by setting appropriate goals and discussing the expected benefits of therapy and how long it will take to achieve them.
• Empower the patients to be actively involved in their own management by encouraging patients to track their own progress through the use of:
    ○ diary cards, flow charts, headache calendars, and
    ○ methods for tracking days of disability or missed work, school, or family activities.
• Create a formal management plan and individualize management: consider the patient’s response to, and tolerance for, specific medications.
• Consider co-morbidity/coexisting conditions that need to be ascertained as they may influence treatment choices.
    ○ Co-morbid conditions: depression, anxiety, obsessive-compulsive disorders
    ○ Co-existing conditions (such as reactive airway disease, hypertension).
To meet these goals:
• Use migraine-specific agents (e.g. triptans) in patients whose headaches respond poorly to nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen.
Failure to use an effective treatment promptly may increase pain, disability, and the impact of the headache. Aspirin containing compounds should not be used in children under the age of 15 due to the risk of Reye syndrome.
• Select a non-oral route of administration for patients with migraine associated with severe nausea or vomiting where the nausea and vomiting restrict the use of oral medications.
Antiemetics should not be restricted to patients who are vomiting or likely to vomit. Nausea itself is one of the most aversive and disabling symptoms of a migraine attack and should be treated appropriately.
• Consider a self-administered rescue medication for patients with severe migraine who do not respond to (or fail) other treatments.
A rescue medication is used when other treatments fail and permits the patient to achieve relief without the discomfort and expense of a visit to the physician’s office or emergency department.
• Guard against medication-overuse headache (“rebound headache” or “drug-induced headache”).
Frequent use of acute medications (including but not limited to opiates, triptans, simple analgesics, and mixed analgesics containing butalbital, caffeine, or isometheptene) is generally thought to cause medication-overuse headache. Many experts limit acute therapy to two headache days per week on a regular basis. Patients with medication overuse should use preventive therapy.