Acute medications (analgesics, triptans) and possibly antiemetics should be taken as early as possible in a migraine attack as this provides greatest efficacy (5). Many more migraine patients should probably try prophylactic treatment; in the event of frequent attacks, early initiation of prophylaxis may prevent the development of daily headaches (chronification) (2). There is no single threshold for starting prophylaxis, but it should be considered if the patient has two to three migraine attacks per month, if acute treatment has limited effectiveness or pronounced adverse effects, or if aura symptoms are incapacitating (2). Before referring the patient to a neurologist, an appropriate dose of beta-blockers and/or angiotensin II receptor blockers should first be tested in general practice for an adequate length of time. Other options are tricyclic antidepressants such as amitriptyline, and antiepileptic drugs such as topiramate and valproate (5). We recommend that each drug be tried out for at least three months. Treatment should be tailored to the individual in accordance with the drug's adverse effect/efficacy profile and any other health problems for which the drug may also be beneficial (5). Effective patient education is very important. Prophylactic treatment can reduce the frequency of attacks and intensity of pain, and enhance the effectiveness of acute treatments, but it very rarely leaves the patient completely headache-free. It may take up to three months for an effect to occur, and it is important that patients are informed of this at the start of treatment. Slow dose escalation is necessary to reduce the risk of adverse effects. Use of a headache diary is recommended to evaluate treatment effectiveness.
Specific advice on non-pharmacological interventions may also enable patients to achieve better control of their migraine attacks. Exercise, diet, normalisation of body weight, and a regular sleep pattern, with neither too little nor too much sleep, may ameliorate headaches. Stress management with different types of relaxation training and cognitive behavioural therapy may also be helpful.
Prophylactic medications should be discontinued prior to planned pregnancy (2). Women who are on prophylactic medication for migraines when a pregnancy is confirmed are advised to discontinue the drug. Many find that their migraines improve during pregnancy (2). If frequent attacks occur despite non-pharmacological prophylaxis, propranolol is the first-line choice for prophylactic medical treatment (7). Amitriptyline and verapamil may also be considered if indicated.