- Recommendations for treatment strategy of migraine.
| 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% |