Article Figures & Data
Figures
- Figure 1
- Recommendations for treatment strategy for adult migraine patients; a) Abortive Treatment for Adults with Migraine; b) Preventive treatment for adults with migraine.
Tables
Strength of Recommendation Definition Implications for stakeholders Strong Recommendation The benefits of the intervention clearly outweigh the risks, and the quality of evidence is high. Clinicians should follow this recommendation in most situations. Patients can be confident in the benefits of the intervention. Conditional Recommendation The benefits of the intervention outweigh the risks, but the quality of evidence is lower or there is uncertainty. Clinicians should consider this recommendation, but individual patient circumstances and preferences should guide decision-making. Patients should be informed about the uncertainty and involved in the decision process. No Recommendation Evidence is lacking to recommend the intervention. Clinicians should use their judgment and consider patient preferences. Further research is required to clarify the overall effectiveness. Weak Recommendation Against The risks of the intervention outweigh the benefits, but the evidence is low in quality. Clinicians should generally avoid this intervention, but individual cases may warrant its use. Patients should be knowledgeable of the potential risks. Strong Recommendation Against The risks of the intervention clearly outweigh the benefits, and the quality of evidence is high. Clinicians should not use this intervention. Patients should be made aware of the strong evidence against its use. - Table 2
- Strength and level of evidence for the recommendations for the abortive treatment.
Recommendations Strength of recommendation Certainty of evidence Percentage of panel agreement Abortive Treatment 1. For the treatment of mild-to-moderate migraine pain, we recommend using paracetamol (acetaminophen) over no treatment. Strong Moderate 100% 2. For the treatment of mild-to-moderate migraine pain, we recommend using ibuprofen over no treatment. Strong Moderate 100% 3. For the treatment of moderate-to-severe migraine pain, we suggest using celecoxib over no treatment. Strong Moderate 91% 4. For the treatment of moderate-to-severe migraine pain, we suggest using sumatriptan over no treatment. Conditional Low 82% 5. For the treatment of acute migraine in patients receiving other triptans or ergotamine within 24 hours, we recommend against using rizatriptan. Strong Very low 91% 6. For the treatment of acute migraine attacks in patients with nausea or vomiting, we suggest using metoclopramide over no treatment. Conditional Low 91% 7. For the treatment of acute migraine in patients receiving other triptans or ergotamine within 24 hours, we recommend against using eletriptan. Strong Very low 91% 8. For the treatment of moderate-to-severe migraine, we suggest using rimegepant over no treatment. Conditional High 100% 9. For the treatment of moderate to severe migraine, we suggest using ubrogepant over no treatment. Conditional Low 82% 10. For the treatment of moderate to severe migraine pain, we recommend using eletriptan over no treatment. Strong High 100% 11. For the treatment of moderate to severe migraine attacks, we suggest against using lasmiditan. Conditional Moderate 82% 12. For the treatment of intractable and status migrainosus, we suggest using valproate over ibuprofen. Conditional Low 100% 13. For the treatment of acute migraine in the emergency department, we suggest using either valproate or dexamethasone. Conditional Very low 100% - Table 3
- Strength and certainty of evidence for the recommendations on the preventive therapy and complementary and alternative medicine.
Recommendation Strength of recommendation Certainty of evidence Percentage of panel agreement 14. For the prevention of episodic or chronic migraine, we recommend using propranolol over no treatment. Strong Moderate 100% 15. For the prevention of episodic or chronic migraine, we recommend using topiramate over no treatment. Strong Moderate 100% 16. For the prevention of episodic or chronic migraine, we suggest using propranolol over topiramate. Conditional Low 100% 17. For the prevention of episodic or chronic migraine, we suggest using valproate over no treatment. Conditional Very low 100% 18. For the prevention of episodic or chronic migraine, we suggest using erenumab over no treatment. Conditional Moderate 82% 19. For the prevention of episodic or chronic migraine, we suggest using fremanezumab over no treatment. Conditional Moderate 91% 20. For the prevention of episodic or chronic migraine, we suggest using galcanezumab over no treatment. Conditional Moderate 82% 21. For the prevention of episodic or chronic migraine, we suggest using eptinezumab over no treatment. Conditional Moderate 82% 22. For the prevention of chronic migraine, we suggest using botulinum toxin over no treatment. Conditional Very low 100% 23. For the prevention of chronic migraine, we suggest using greater occipital nerve block over no treatment Conditional Very low 91% 24. For the prevention of episodic or chronic migraine, we suggest using atogepant over no treatment. Conditional Low 100% 25. For the prevention of episodic or chronic migraine, we recommend using amitriptyline over no treatment (strong recommendation, low certainty of evidence). Strong Low 100% 26. For patient with low serum vitamin D level and chronic migraine, we suggest using vitamin D replacement over no treatment. Conditional Low 82% Recommendation Percentage of panel Agreement Acute Migraine Treatment 1. For mild to moderate attacks of migraine headache in adults, we recommend paracetamol or NSAIDs or a combination as the first-line abortive treatment. 100% 2. For mild to moderate attacks of migraine headache in adults associated with nausea and vomiting, we recommend using metoclopramide with paracetamol or NSAIDs or a combination as the first-line abortive treatment option. 100% 3. For mild to moderate attacks of migraine headache in adults with poor response to the first line abortive treatment, we suggest using triptans as the second-line abortive treatment. 100% 4. For severe attacks of migraine headache in adults, we recommend a trial of paracetamol or NSAIDs or a combination as the first-line abortive treatment. 70% 5. For severe attacks of migraine headache in adults associated with nausea and vomiting, we recommend using metoclopramide with paracetamol or NSAIDs or a combination as the first-line abortive treatment. 100% 6. For severe attacks of migraine headache in adults with poor response to the first-line abortive treatment, we recommend using triptans as the second-line abortive treatment. 70% 7. For adults with moderate to severe acute migraine with either insufficient response to two different triptans or contraindication to treatment with triptans, we suggest using CGRP antagonists (gepants) as a third-line abortive treatment prescribed by the neurologist 100% 8. For intractable acute migraine attacks (status migrainosus), we suggest using intravenous sodium valproate as a third-line abortive treatment option. 100% Episodic migraine prophylactic treatment 9. For adults with episodic migraine, we suggest using propranolol as the first line prophylactic agent. 90% 10. For adults with episodic migraine, we suggest using amitriptyline as the second line prophylactic agent. 90% 11. For adults with episodic migraine, we suggest using topiramate as the third line prophylactic agent. 100% 12. For adults with episodic migraine, we suggest using valproate as the fourth line prophylactic agent. 90% 13. For adults with episodic migraine who have not benefitted or tolerated appropriate trials of three or more oral migraine prophylactic treatments. we suggest using erenumab or atogepant as the fifth line prophylactic agent. If these agents are not available or there was poor clinical response we suggest using eptinezumab, fremanezumab or galcanezumab. 70% Chronic migraine prophylactic treatment 14. For adults with chronic migraine, we suggest using propranolol as the first line prophylactic agent. 100% 15. For adults with chronic migraine, we suggest using amitriptyline as the second line prophylactic agent. 90% 16. For adults with chronic migraine, we suggest using topiramate as the third line prophylactic agent. 100% 17. For adults with chronic migraine, we suggest using valproate as the fourth line prophylactic agent. 90% 18. For adults with chronic migraine who have not benefitted or tolerated appropriate trials of three or more oral migraine prophylactic treatments. we suggest using erenumab or atogepant as the fifth line prophylactic agent. If these agents are not available or there was poor clinical response we suggest using eptinezumab, fremanezumab or galcanezumab. 70% 19. For adults with chronic migraine, we suggest using botulinum toxin as prophylactic agent in patients who have not benefitted from appropriate trials of four or more migraine prophylactic treatments. 70%
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