International

There are international guidelines available for migraine diagnosis but not for treatment (Manack et al., 2009; International Headache Society, 2018). However, there are several local guidelines available to assist in treating migraine patients effectively.

Diagnosis of migraine

Click here to return to the diagnosis section for information on diagnosis guidelines.

Management of migraine

In the US there are treatment guidelines for treating episodic and chronic migraine and also for prophylaxis (Silberstein, 2000; Silberstein et al., 2012; Marmura et al., 2015; Simpson et al., 2016).

Table 5: Available US treatment guidelines

Available US treatment guidelines.


Guidelines for acute treatment of migraine

In Europe, there are European Headache Federation (EHF) guidelines for managing headache (Steiner & Martelletti, 2007) and European Federation of Neurological Sciences (EFNS) guidelines on the drug treatment of migraine (Evers et al., 2009).

EHF guidelines are available in a number of languages.

Medical management of acute migraine.

Figure 16: Medical management of acute migraine (Steiner & Martelletti, 2007).

The EHF also offers advice on migraine management in primary care.

Table 6: Principles of migraine management in primary care, EHF guidelines (Steiner & Martelletti, 2007).

Principles of migraine management in primary care, EHF guidelines (Steiner & Martelletti, 2007).


Guidelines for initiating migraine prevention treatments

EHF guidelines also offer clear advice on when to use preventive treatment (Steiner & Martelletti, 2007). They recommend initiating preventive therapy, in combination with acute treatment, in adults and children with impaired quality of life, identified by (Steiner & Martelletti, 2007):

  • attacks causing disability ≥2 days/month and optimising acute therapy does not prevent this
  • patient is willing to take daily medication
  • a child has frequent absences from school

EHF guidelines also highlight the risk of over-use of acute therapies, even when the treatment is effective. Migraine prevention drugs are inappropriate for MOH (Steiner & Martelletti, 2007).

There are also US Guidelines for initiating preventive therapy (Silberstein, 2015).

  • Dosing and titration: Start with a low dose and titrate slowly.
  • Contraindications: Consider comorbidity and coexisting illnesses; avoid therapies that exacerbate or are overused and contraindicated.
  • Initiation: Provide an adequate treatment trial (2–6 months) to achieve maximal therapeutic response, while setting realistic goals. For example, success defined as 50% reduction in attack frequency or headache days.
  • Follow-up: Re-evaluate therapy; migraine may improve or subside independent of treatment. Involve patients in their care to maximise adherence to treatment.
  • Women of child-bearing age: Educate women of childbearing age on risk of therapies; avoid use in anticipation of or during pregnancy.