What Is Episodic Migraine (FRESH — Release)

The hypothalamus (especially the suprachiasmatic nucleus) is now considered the master trigger. It processes homeostatic signals (sleep, hunger, stress, circadian rhythm). Abnormal hypothalamic activation occurs the headache phase, explaining prodromal symptoms like yawning, food cravings, or fatigue.

| Drug Class | Examples | Best for | Key Caution | |------------|----------|----------|--------------| | | Sumatriptan, rizatriptan, eletriptan | Moderate-severe pain, with nausea | Not in cardiovascular disease; max 2-4 doses/week to avoid MOH | | Gepants (CGRP receptor antagonists) | Ubrogepant, rimegepant | Triptan intolerance, cardiovascular risk | No vasoconstriction; mild nausea possible | | Ditans (5-HT1F agonists) | Lasmiditan | Triptan non-responders, CV risk | Dizziness, fatigue common; no vasoconstriction | | NSAIDs | Ibuprofen, naproxen, diclofenac | Mild-moderate pain | Gastric irritation; limit use | | Anti-emetics | Metoclopramide, prochlorperazine | Severe nausea/vomiting, also analgesic | Extrapyramidal symptoms (rare) | | Non-specific | Acetaminophen (paracetamol) | Mild pain, pregnancy | Hepatotoxicity at high doses | what is episodic migraine

| Condition | Distinguishing Features | |-----------|--------------------------| | | Bilateral, pressing/light pressure (not throbbing), mild/moderate, no nausea or photophobia+phonophobia simultaneously | | Sinus headache | Facial pressure, purulent nasal discharge, fever; actually most "sinus headaches" meet migraine criteria | | Cluster headache | Severe, orbital/periorbital, 15–180 min, autonomic features (tearing, rhinorrhea, ptosis), circadian periodicity | | Medication-overuse headache | Worsening headache with frequent acute medication use; improves after withdrawal | | Thunderclap headache | Sudden onset to peak <1 min—consider subarachnoid hemorrhage, reversible cerebral vasoconstriction syndrome (RCVS) | | Drug Class | Examples | Best for

| Drug Class | Examples | Evidence Level | Common Side Effects | |------------|----------|----------------|----------------------| | | Propranolol, metoprolol | High | Fatigue, cold extremities, bradycardia | | Anticonvulsants | Topiramate, valproate | High (topiramate) | Paresthesias, word-finding difficulty, weight loss (topiramate); teratogenicity | | Antidepressants | Amitriptyline, venlafaxine | Moderate | Dry mouth, sedation, weight gain | | CGRP mAbs | Erenumab, galcanezumab, fremanezumab | High | Injection site reactions; low systemic toxicity | | Gepants (oral preventive) | Atogepant, rimegepant | High | Constipation, nausea | | Botulinum toxin A | OnabotulinumtoxinA | Only for chronic migraine | Neck weakness, dysphagia (rare) | eletriptan | Moderate-severe pain