Migraine Management Medical Slides

Present stratified care based on attack severity rather than step care: mild attacks (NSAIDs ± metoclopramide), moderate-severe (triptans — sumatriptan remains first-line, or gepants for triptan contraindications/failure), severe with nausea (parenteral therapy: sumatriptan SC, ketorolac IM, metoclopramide IV). Emphasize treating early, antiemetic co-therapy, and the 2-day/week limit to prevent medication overuse headache per the 2021 AHS consensus.

Present the four CGRP monoclonal antibodies: erenumab (receptor antagonist), fremanezumab, galcanezumab, eptinezumab (ligand antibodies). Average reduction is 3-4 migraine days/month with 50% responder rates of 50-60%. Reference key trials: STRIVE (erenumab), HALO (fremanezumab), EVOLVE (galcanezumab). Discuss oral CGRP receptor antagonists (rimegepant, atogepant) for both acute and preventive use — a unique dual indication.

Define MOH as headache ≥15 days/month in a patient using acute medications ≥10-15 days/month (depending on medication type) for >3 months. Present the ICHD-3 criteria and the vicious cycle of overuse leading to chronification. Teach the management approach: start preventive therapy (bridge with a short steroid course if needed), withdraw the overused medication (abrupt for triptans, gradual taper for opioids/barbiturates), and set clear treatment day limits (≤2 days/week).