What are the treatment options for Migraine (headache disorder)?

From the Guidelines

For the treatment of migraine, start with over-the-counter medications like ibuprofen (400-600mg) or naproxen (500-550mg) at the first sign of headache, as recommended by the most recent guideline from the American College of Physicians 1.

Acute Treatment

• For mild episodic migraine headache, consider treating with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen 1.
• If the migraine is moderate to severe, consider using a triptan, such as sumatriptan (50-100mg orally) or rizatriptan (10mg), in combination with an NSAID or acetaminophen 1.
• For severe nausea, add an antiemetic like metoclopramide (10mg) to the treatment regimen 1.
• Consider using a nonoral triptan and an antiemetic in people having severe nausea or vomiting 1.

Preventive Treatment

• Preventive treatment is recommended for frequent migraines (4+ monthly) and includes propranolol (40-160mg daily), topiramate (25-100mg daily), or amitriptyline (10-100mg nightly) 1.
• Newer options include CGRP antagonists like erenumab (70-140mg monthly injection) or rimegepant (75mg every other day) 1.
• Non-pharmacological approaches are also important: identify and avoid triggers (certain foods, stress, irregular sleep), maintain regular sleep patterns, stay hydrated, and practice stress management techniques like meditation 1.

Important Considerations

• Do not use opioids or butalbital for the treatment of acute episodic migraine 1.
• Counsel patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy (such as a triptan with an NSAID or acetaminophen) to improve efficacy 1.
• Patients should be aware of medication overuse headache, which is a potential complication of migraine treatment 1.

From the FDA Drug Label

The efficacy of rizatriptan benzoate orally disintegrating tablets in pediatric patients 6 to 17 years was evaluated in a multicenter, randomized, double-blind, placebo-controlled, parallel group clinical trial (Study 7) Patients had to have at least a 6 month history of migraine attacks (with or without aura) usually lasting 3 hours or more (when untreated). The patient population was historically non-responsive to NSAIDs and acetaminophen therapy. Patients were instructed to treat a single migraine attack with headache pain of moderate to severe intensity. The treatment phase of the study had two stages Stage 1 was used to identify placebo non-responders, who then entered into Stage 2, in which patients were randomized to rizatriptan benzoate orally disintegrating tablets or placebo Using a weight-based dosing strategy, patients 20 kg to <40 kg (44 lb to <88 lb) received rizatriptan benzoate orally disintegrating tablets 5 mg or placebo, and patients ≥40 kg (88 lb) received rizatriptan benzoate orally disintegrating tablets 10 mg or placebo. The mean age for the studied patient population was 13 years Sixty-one percent of the patients were Caucasian, and fifty-six percent of the patients were female. The percentage of patients achieving the primary efficacy endpoint of no headache pain at 2 hours after treatment was significantly greater in patients who received rizatriptan benzoate orally disintegrating tablets, compared with those who received placebo (33% vs. 24%)

Treatment of Migraine:

• Rizatriptan benzoate is effective in the treatment of migraine attacks in patients with or without aura.
• The efficacy of rizatriptan benzoate was evaluated in a clinical trial (Study 7) in pediatric patients 6 to 17 years, and the results showed that the percentage of patients achieving no headache pain at 2 hours after treatment was significantly greater in patients who received rizatriptan benzoate orally disintegrating tablets, compared with those who received placebo (33% vs. 24%) 2.
• Sumatriptan also binds with high affinity to human cloned 5-HT1B/1D receptors and presumably exerts its therapeutic effects in the treatment of migraine headache through agonist effects at the 5-HT1B/1D receptors on intracranial blood vessels and sensory nerves of the trigeminal system 3.
• It is essential to note that rizatriptan benzoate should not be given to patients with ischemic or vasospastic coronary artery disease, and patients with multiple cardiovascular risk factors should have a cardiovascular evaluation prior to receiving rizatriptan benzoate 2.

From the Research

Treatment Options for Migraine

• Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, antiemetics, ergot alkaloids, and combination analgesics have evidence supporting their effectiveness in the treatment of migraine 4
• Over-the-counter medications, such as acetaminophen, ibuprofen, naproxen, and aspirin, are considered a first-line therapy for most migraineurs and have shown strong efficacy when used as first-line treatments for mild-to-moderate migraine attacks 5
• Triptans are first-line treatments for moderate to severe migraines, but may be expensive 4
• Sumatriptan plus naproxen is a combination treatment that has been shown to be effective in the acute treatment of migraine headaches, with a greater effect than either monotherapy, but with more adverse events 6

Pharmacologic Properties and Adverse Effects

• The pharmacologic properties, potential adverse effects, cost, and routes of administration of migraine treatments vary widely, allowing therapy to be individualized based on the pattern and severity of attacks 4
• Adverse events associated with sumatriptan plus naproxen are mostly mild or moderate in severity and rarely lead to withdrawal, but are more common with the combination than with placebo 6
• Rizatriptan has been compared to sumatriptan in several studies, with 10 mg rizatriptan having a more rapid onset of action and resulting in more patients being pain-free after 2 hours, but with a higher incidence of adverse events at higher doses 7

Treatment Principles and Recommendations

• Taking medication early in an attack and using a stratified treatment approach can help ensure that migraine treatment is cost-effective 4
• Patients who experience disability during the predominance of their attacks are poor candidates for over-the-counter-exclusive therapy and should seek a physician's help for migraine-specific prescription drugs 8
• Pharmacists are well positioned to assess whether patients could benefit from over-the-counter agents or should seek a physician's assistance 8