Avoidance of triggers plays an important role in treatment. Common triggers include; emotional stress, menses, oral contraceptives, alcohol (especially red wine), weather changes, fasting, neck pain, bright light, and disrupted sleep patterns.
Triptans are considered the first line treatment after failure of NSAIDs. They act by stimulating serotonin 1b/1d receptors, and inhibiting the release of the vasoactive peptides known to cause neurogenic inflammation.
Nonsteroidal anti-inflammatory drugs are a first line treatment for migraines, and should be used before other medications. Different NSAIDs may have different efficacy from patient to patient, so several should be tried before escalating treatment.
Preventative treatment may be warranted in patients with frequent or severe migraines, or those that have failed abortive treatments. Beta blockers are effective in preventing migraines when taken daily. Use with caution in smokers and patients over 60, as they may increase the risk of stroke in these populations.
Several Ca2+ channel blockers may be tried in patients who have failed or have contraindications to Beta Blocker therapy. The mechanism in which they work for migraines is unknown.
Amitriptyline is a tricyclic antidepressant that acts by inhibiting reuptake of serotonin and norepinephrine. It is effective for preventing migraine, but has a large side-effect profile including sedation and anticholinergic toxicity.
The anticonvulsants Topiramate and Valproate have been shown to decrease migraine frequency by up to 50%. Remember that Valproate is teratogenic, and therefore contraindicated in pregnancy!
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