Alyssa Matulich
Migraine Prophylaxis
Clinical Presentation: episodic headaches that last 4 to 72 hours and may be
associated with nausea, vomiting, photophobia, and phonophobia. The pain is
typically described as a pounding or throbbing, unilateral, and of moderate to
severe intensity.
H&P a complete history including family history, medications, and through
review of systems. The physical exam is done to rule out secondary
pathologies with major focuses on cardiopulmonary and neurologic
assessments.
Differential Diagnosis: infection, tension headaches, cluster headache, head
or neck trauma, intracranial lesion, TIA, seizure, syncope, thyroid
dysfunction, rheumatologic disorder, temporal arteritis, trigeminal neuralgia
Diagnostic Criteria:
• Migraine without aura
o At least five attacks lasting 4-72 hours with:
§ At least 2: unilateral location, pulsating quality,
moderate/severe pain intensity, aggravation by
physical activity
§ At least 1: nausea, vomiting, photophobia, and
phonophobia
• Migraine with Aura
o At least two attacks with
§ At least one of the following fully reversible aura
symptoms: Vision, sensory, speech, motor,
brainstem, retinal
§ At least 2: one aura symptom spreads gradually of 5
minutes and with 2 or more symptoms succeeding,
individual aura symptoms last 5-60 min, at least one
aura symptom is unilateral, aura is accompanied or
followed within 60 min by headache
§ o More expensive and a lot of side effects
Diagnostic testing: neuroimaging not necessary unless unexplained
abnormal neuro logic exam or red flag then do CT with contrast or MRI.
Labs: CBC with diff, CRP, ESR, TSH, Lyme titer, RH factor, CSF analysis
Abbreviated References: UptoDate; Uphold and Graham; Buttaro, Trybulski, Polgar-Bailey, and Sandburg-Cook
Red Flags: first/worst headache; change in pattern, frequency or severity;
always on same side; not responding to treatment; new onset after 50 years of
age; new- onset with cancer or HIV; associated symptoms such as fever, stiff
neck, cognitive impairment
Plan/Management:
Indications:
• Frequent long-lasting migraine headaches
• Attacks that cause significant disability or diminished quality of life
• Contraindication or failure of acute therapies
• Risk of medication overuse headache
• Menstrual migraine
Medications
• Beta Blockers
o Options include: Metoprolol 25mg twice a day, Propranolol
20mg twice a day
o May take several weeks to see improvement; should be
maintained for three months before deeming failure
o NOT for initial therapy for patients over 60 and smokers
o Use cautiously in pts with asthma, DM, depression
• Antidepressants
o Options include: amitriptyline 10mg at bedtime, venlafaxine
37.5mg once daily
o Watch for sedation and anticholinergic side effects
• Anticonvulsants
o Options include: Topamax 25mg daily, valproate 500mg
daily
o Do not use in pregnancy or women of childbearing age
Education
• Good sleep hygiene, routine meals, regular exercise, managing
triggers, headache diary
References:
Bajwa, Z. H., & Smith, J. H. (2018, March 2). Preventive treatment of
migraine in adults. Retrieved from https://www-uptodate-
com.proxy.lib.utc.edu/contents/preventive-treatment-of-migraine-in-
adults?search=migraineprophylaxis&source=search_result&selected
Title=1~80&usage_type=default&display_rank=1

Buttaro, T.M, Trybulski, J., Polgar-Bailey, P., Sandburg-Cook, J. (2017).

Primary Care: A Collaborative Practice. (5th ed.). Mosby.

Cutrer, M. F., & Bajwa, Z. H. (2017, November 13). Pathophysiology,

clinical manifestations, and diagnosis migraine in adults. Retrieved
fromhttps://wwwuptodatecom.proxy.lib.utc.edu/contents/pathophysi
ology-clinical-manifestations-and-diagnosis-of-migraine-in-
adults?topicRef=3345&source=see_link

Uphold, C. & Graham, M. (2013). Clinical Guidelines in Family Practice.

Barmarrae Books, Inc. (5th ed). ISBN 978-0964615199

Abbreviated References: UptoDate; Uphold and Graham; Buttaro, Trybulski, Polgar-Bailey, and Sandburg-Cook