Neftaly Migraine Management Guidelines

1. Introduction

Migraine is a common and disabling neurological disorder that affects people of all ages and backgrounds. It is characterized by recurring headaches, often accompanied by nausea, vomiting, and sensitivity to light or sound.

The Neftaly Migraine Management Guidelines aim to provide healthcare providers with a standardized, evidence-based approach for the diagnosis, treatment, and long-term management of migraines. These guidelines are tailored for both primary care and community health settings to ensure accessible and effective care for all patients.

---

2. Objectives

• Improve accurate diagnosis of migraine in diverse clinical settings
• Guide evidence-based acute and preventive treatment
• Reduce migraine frequency, severity, and impact on quality of life
• Promote patient education and self-management
• Ensure safe referral of complex or refractory cases

---

3. Understanding Migraine

3.1 Types of Migraine

Type	Description
Migraine without Aura	Most common type; moderate to severe pulsating headache, often one-sided, with nausea and sensitivity to light/sound.
Migraine with Aura	Headache preceded by reversible visual, sensory, or speech disturbances.
Chronic Migraine	Headache occurring ≥15 days/month for ≥3 months, with features of migraine on ≥8 days/month.
Menstrual Migraine	Occurs around menstruation, often without aura.

3.2 Common Triggers

• Stress or emotional disturbance
• Hormonal changes
• Skipped meals or dehydration
• Certain foods (e.g., aged cheese, chocolate, caffeine)
• Bright lights or loud noise
• Sleep disturbances
• Weather changes

---

4. Diagnostic Criteria (ICHD-3)

Migraine without Aura:

• At least 5 attacks fulfilling the following:
  • Lasts 4–72 hours
  • At least 2 of the following: unilateral, pulsating, moderate to severe, aggravated by activity
  • At least 1 of the following: nausea/vomiting or photophobia/phonophobia

Migraine with Aura:

• At least 2 attacks with:
  • Fully reversible aura symptoms (visual, sensory, speech)
  • At least 1 aura symptom develops gradually over ≥5 minutes
  • Headache begins during or within 60 minutes after aura

---

5. Acute Migraine Management

5.1 First-Line Treatments

• Mild to Moderate:
  • Paracetamol (1000 mg)
  • NSAIDs (e.g., Ibuprofen 400–600 mg or Naproxen 500 mg)
• Moderate to Severe or Non-Responsive to First-Line:
  • Triptans (e.g., Sumatriptan 50–100 mg oral or 6 mg SC)
  • Combination therapy: Triptan + NSAID

5.2 Adjunctive Treatments

• Antiemetics: Metoclopramide 10 mg or Domperidone 10 mg
• Adequate hydration and rest in a quiet, dark room

5.3 Avoid Overuse

• Limit use of acute medications to ≤2 days/week to prevent medication-overuse headache (MOH)

---

6. Preventive (Prophylactic) Treatment

When to Start Preventive Therapy:

• ≥4 migraine days/month
• Significant disability despite acute treatment
• Contraindications to acute therapies
• Preference of the patient

Common Preventive Medications:

Drug Class	Examples	Notes
Beta-blockers	Propranolol, Metoprolol	Avoid in asthma, bradycardia
Antidepressants	Amitriptyline, Nortriptyline	Useful if coexisting depression or insomnia
Anticonvulsants	Topiramate, Valproate	Caution in pregnancy
CGRP Inhibitors	Erenumab, Fremanezumab	For refractory cases, costly
Calcium Channel Blockers	Verapamil	Sometimes used off-label

Start low, go slow — monitor for side effects and effectiveness. Treatment trial should last at least 2–3 months before assessing benefit.

---

7. Non-Pharmacological Management

7.1 Lifestyle Modifications

• Regular sleep, meals, and exercise
• Hydration and caffeine moderation
• Identify and avoid personal triggers
• Stress reduction techniques: mindfulness, yoga, breathing exercises

7.2 Behavioral Therapies

• Cognitive Behavioral Therapy (CBT)
• Biofeedback or relaxation therapy
• Patient migraine diaries for trigger tracking

---

8. Migraine in Special Populations

8.1 Pregnancy and Breastfeeding

• Prefer paracetamol for acute treatment
• Avoid NSAIDs (especially in 3rd trimester) and most triptans
• Preventive treatment discouraged unless necessary; non-drug strategies preferred

8.2 Children and Adolescents

• Use weight-appropriate doses of ibuprofen or paracetamol
• Lifestyle modifications crucial
• Avoid adult-specific preventives unless guided by a specialist

---

9. Referral Guidelines

Refer to a neurologist or headache specialist if:

• Diagnosis is uncertain (e.g., red flags suggesting secondary causes)
• Severe or disabling migraines despite treatment
• Chronic migraine or medication-overuse headache
• Neurological symptoms (e.g., weakness, confusion) during aura
• Need for advanced therapy (e.g., CGRP inhibitors, Botox)

---

10. Red Flags: “SNOOP” for Secondary Headaches

Red Flag	Indicator
S – Systemic	Fever, weight loss, cancer, HIV
N – Neurological signs	Confusion, weakness, visual changes
O – Onset	Sudden or thunderclap headache
O – Older age	First onset after age 50
P – Pattern change	Progressively worsening or new type

Urgent evaluation (CT/MRI) needed if any red flags are present.

---

11. Patient Education and Support

• Teach patients to:
  • Recognize early signs of migraine
  • Maintain a headache diary
  • Use medications correctly
  • Understand the importance of preventive measures
• Provide written action plans and emergency contacts

---

12. Monitoring and Evaluation

• Assess frequency, severity, and impact of migraine monthly
• Use tools like:
  • MIDAS (Migraine Disability Assessment)
  • HIT-6 (Headache Impact Test)
• Adjust treatment based on response and side effects

---

13. Conclusion

Migraine is manageable with the right combination of medication, lifestyle, and education. Neftaly’s Migraine Management Guidelines empower frontline healthcare workers to deliver effective, compassionate, and timely care — reducing the burden of migraines on individuals, families, and health systems.

---

For clinical tools, referral protocols, or training support, contact the Neftaly Neurology and Non-Communicable Disease Unit.