The latest expert consensus on migraine diagnosis and treatment, 3 minutes to understand!

 

Migraine is a common primary headache disease that directly affects more than 1 billion people worldwide
.

Despite the high incidence of migraine, there is still no better diagnosis and treatment method

Consensus on diagnosis and treatment

The consensus content includes typical clinical features, diagnostic criteria, and differential diagnosis of migraine , and outlines the best treatment methods for different groups of people, including adults, children , adolescents, pregnant women, lactating women, and the elderly
.

In addition, the statement also provides suggestions on how to evaluate if treatment fails

Diagnose children

 

Step 1: When is migraine suspected?

Step 1: When is migraine suspected? Step 1: When is migraine suspected?

There are three main types of migraine: migraine with aura, migraine without aura, and chronic headache
.

Migraine without aura is suspected for patients with recurrent moderate to severe headache accompanied by symptoms such as photophobia, phonophobia, nausea, and/or vomiting, especially when the headache is unilateral and/or pulsatile
.

For patients who have experienced the above symptoms and recurrent short-term vision and/or unilateral sensory disturbances, migraine with aura is suspected
.

For patients who have headaches for more than 15 days within a month, chronic migraine is suspected
.

Especially for those who have a family history of migraine, such as chronic migraine, symptoms usually appear in or around puberty

 

Step 2: Diagnosis of migraine

Step 2: Diagnosis of Migraine Step 2: Diagnosis of Migraine

Medical history is the main basis for the diagnosis of migraine , and a complete medical history record should provide enough information for doctors to make a diagnosis based on the ICHD-3 standard
.

Effective diagnostic aids and screening tools such as headache diary, ID-Migraine and Migraine Screening Questionnaire can be used when recording the medical history

Medical history is the main basis for the diagnosis of migraine screening

At the time of diagnosis, attention should be paid to distinguishing from other primary and secondary headaches, especially some secondary headaches may be life-threatening when severe (such as meningitis)
.

Neuroimaging methods should only be used when secondary headaches are suspected because of the hazards of ionizing radiation
.

MRI is superior to CT because MRI can provide higher resolution and avoid exposure to ionizing radiation

 

Step 3: Education and patient-centered

Step 3: Education and patient-centered

Patient-centeredness and education play an important role in migraine treatment
.

Doctors should explain to each patient what migraine is and how to deal with it, including explaining that migraine is difficult to be cured, reducing unrealistic expectations of patients, and instructing patients on how to use drugs correctly and coping with adverse reactions

Patient-centeredness and education play an important role in migraine treatment

 

Step 4: Acute treatment

Step 4: Acute treatment

It is recommended to provide acute medication for all migraine sufferers
.

The effectiveness of the drug is related to the correct timing and dosage, and it is best to use it early in the onset of headaches

Acute treatment can be divided into first-line, second-line, third-line and adjuvant therapy, and stepwise treatment should be used

Use triptans as second-line drugs
.
If symptoms recur, you can use triptans repeatedly, or use non-steroidal drugs at the same time
.
However, patients should be warned that frequent and repeated use of acute drugs has the risk of MOH (headache caused by overuse of drugs)
.

Consider CGRP receptor antagonists (Gepants) and ditan as third-line drugs
.

Use prokinetic antiemetics (domperidone or metoclopramide) as an oral supplement for nausea and/or vomiting
.

Avoid oral ergot alkaloids, opioids and barbiturates
.
Ergot alkaloids are ineffective and potentially toxic.
Opioids and barbiturates have uncertain efficacy and have considerable side effects and dependence
.

Migraine medication list

 

Step 5: Preventive treatment

Step 5: Preventive treatment

For patients whose lives are still affected by migraine despite optimized acute treatment, additional preventive treatment should be considered
.
Generally, preventive treatment is considered for patients who are affected by migraine for more than 2 days per month, but this standard is not absolute.
Doctors should also consider the severity, duration, other dysfunctions related to migraine and whether Overdose has been taken
.

For patients whose lives are still affected by migraine despite optimized acute treatment, additional preventive treatment should be considered
.

Preventive treatment can also be divided into first-line, second-line and third-line.
The actual drug selection should be determined according to local guidelines, availability and reimbursement policies
.

Use beta blockers (atenolol, bisoprolol, metoprolol, or propranolol), topiramate, or candesartan as first-line drugs
.

Use flunarizine, amitriptyline, or (male) sodium valproate as second-line drugs
.

Consider CGRP monoclonal antibody as a third-line drug
.

Consider neuromodulation devices, biological behavior therapy, and acupuncture as adjuncts to acute and preventive drug treatments, or as independent preventive treatments when there are drug contraindications

Acupuncture

Prophylactic treatment takes a long time to take effect, and patients should be discouraged from giving up treatment in the early stage of treatment because the effect is not obvious
.
For oral preventive medications, consider changing the therapy after 2-3 months are still ineffective.
The evaluation time for CRGP or its receptor monoclonal drugs is 3-6 months later, and the botulinum A drug is 6-9 Months later
.

 

Step 6: Migraine treatment for special populations

Step 6: Migraine treatment for special populations

The incidence of secondary headaches increases with age.
For migraine patients older than 50 years old, the underlying cause should be considered, and the known and unknown comorbidities and side effects of drugs should also be considered , because the elderly are often The side effects of drugs are more sensitive
.
For example, it does not recommend the use of triptan drugs for the elderly, because such patients suffering from heart blood vessel is a high possibility of the disease
.
If used, it is recommended to regularly check the patient's blood pressure and assess the risk of cardiovascular disease
.

For migraine patients older than 50 years should be considered a potential cause, it should also consider known and unknown complications and side effects of drugs heart blood vessels

Migraines are common among teenagers and children
.
The diagnosis is the same as in adults, mainly based on medical history, but the clinical features are slightly different: the onset time is generally shorter, headaches are more common on both sides, and gastrointestinal disorders are more pronounced
.
Compared with children, parents’ descriptions may be more reliable and can better illustrate possible problematic life>
.
In terms of treatment, for children with a short onset time, bed rest is sufficient
.
When needed, it is recommended to use ibuprofen as a first-line drug, and the dosage is adjusted with body weight
.

Migraines are common among teenagers and children
.

For pregnant women, special consideration should be given to the harm to the fetus
.
Although the efficacy is relatively poor, paracetamol should still be used as a first-line drug, and triptans can only be used under the strict supervision of experts
.
For nausea associated with migraine during pregnancy, metoclopramide can be used
.
Because of the potential for harm to the fetus, it is best to avoid the use of preventive drugs during pregnancy
.
If necessary, the safest propranolol should be used.
If propranolol is contraindicated, amitriptyline should be used
.
Both should be used under expert supervision .
Banning topiramate, candesartan and sodium valproate will cause harm to the fetus
.

For pregnant women, special consideration should be given to the harm to the fetus
.

Medications for migraine after childbirth must also be used with caution .
Paracetamol is the first choice for acute medication, and ibuprofen and sumatriptan are also safe
.
If preventive treatment is required, propranolol, which is the safest, is the first choice
.

Migraine medication after childbirth must also be used with caution

Approximately 8% of women with migraine suffer from menstrual-related migraine attacks
.
If acute medication cannot meet the needs, consider using perimenstrual prophylactic treatment, usually using long-acting non-steroidal anti-inflammatory drugs or triptans daily for 5 days, starting 2 days before the expected menstruation
.
Some women with migraine without aura can benefit from continuous compound hormonal contraceptives, but women with migraine with aura increase the risk of stroke, and compound hormonal contraceptives should be contraindicated
.

If acute medication cannot meet the needs, consider using perimenstrual prophylactic treatment.

 

Step 7: Follow-up, treatment effect and treatment failure

Step 7: Follow-up, treatment effect and treatment failure

Active follow-up is the best way to determine the treatment effect.
The treatment effect should be evaluated after starting or changing the treatment plan (2-3 months later), and then regularly (every 6-12 months)
.
The assessment content includes effectiveness, adverse reactions and compliance
.
The key indicators of effectiveness are frequency, severity, and dysfunction associated with migraine
.
The frequency of attacks is measured by the number of headache days per month, and the severity is the intensity of the pain rather than the functional consequence
.
Patients can be required to record and form a pain calendar when a headache occurs, and a better follow-up effect can be obtained with less investment
.
When the result is not up to the optimal standard, recheck the diagnosis, treatment plan, dosage and compliance
.

Active follow-up is the best way to determine the treatment effect.
The treatment effect should be evaluated after starting or changing the treatment plan (2-3 months later), and then regularly (every 6-12 months)
.

The conclusion of treatment failure should be drawn carefully, and the possible causes should be thoroughly reviewed afterwards
.
Some failures can be remedied, such as poor compliance or inappropriate dosage
.
Some people are suitable for large doses, and some people need to reduce the dose to reduce side effects
.
If all treatment options fail, consider whether the diagnosis is misaligned and seek expert advice
.

 

Step 8: Treat complications

Step 8: Treat complications

Patients should be reminded as soon as possible that excessive medication may cause MOH
.
Medication-induced headache (MOH) is a chronic headache disorder characterized by headaches of 15 days or more per month
.
Stopping the medication is the necessary and only remedy
.
The consensus of experts is that sudden withdrawal is preferable to slow withdrawal, with the exception of addictive drugs such as opioids
.
Since there will be a period of deterioration before recovery, special attention should be paid to patient education
.

Stopping the medication is the necessary and only remedy
.

Be aware of the risk of intermittent migraines turning into chronic migraines
.
Some evaluation data indicate that 3% of intermittent headaches each year will turn into chronic migraine, and treatment will become more difficult.
Expert advice can be sought during treatment
.
After the possibility of MOH was ruled out, preventive treatment was started
.
Effective drugs include topiramate, botulinum toxin A, and CGRP monoclonal antibodies
.
Topiramate can be the first choice because of its lower cost
.
The specific medication should be determined according to local guidelines, cost and reimbursement policies
.

 

Step 9: Identify and treat comorbidities

Step 9: Identify and treat comorbidities

Make sure to identify the comorbidities of migraine, and adjust the treatment strategy according to the possible adverse reactions and complications between different drugs
.

Make sure to identify the comorbidities of migraine, and adjust the treatment strategy according to the possible adverse reactions and complications between different drugs
.

Migraines are often associated with anxiety, depression, sleep disturbances, and chronic pain (such as neck and lower back pain)
.
Obesity is a risk factor for the conversion of intermittent migraine to chronic migraine
.
For obese patients, topiramate may be the first choice because it is associated with weight loss
.
For patients with depression or sleep disorders, amitriptyline can be preferred
.

 

Step 10: Long-term follow-up

Step 10: Long-term follow-up

When the preventive treatment is carried out for up to 6 months, the continuous effect can be seen and there are no adverse reactions.
After a comprehensive treatment plan is drawn up, the patient can be transferred to the first-level hospital.
The first-level hospital is responsible for the long-term health management of migraine patients .
The tasks include Ensure the stability of the curative effect and respond to changes in the condition
.

manage

 

All of the above recommendations are based on published evidence and expert opinions, and aim to provide universally applicable recommendations for the diagnosis and treatment of migraine.
However, in clinical practice, attention should be paid to adjusting the treatment strategy based on local conditions
.

 

Original source:

Original source:

Harrison, SA, Ruane, PJ, Freilich, BL  et al.
 Efruxifermin in non-alcoholic steatohepatitis: a randomized, double-blind, placebo-controlled, phase 2a trial.
  Nat Med  27,  1262–1271 (2021).
https:/ /doi.
org/10.
1038/s41591-021-01425-3

Harrison, SA, Ruane, PJ, Freilich, BL  et al.
 Efruxifermin in non-alcoholic steatohepatitis: a randomized, double-blind, placebo-controlled, phase 2a trial.
  Nat Med  27,  1262–1271 (2021).
https:/ /doi.
org/10.
1038/s41591-021-01425-3 et al.
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