From the Guidelines
Migraine treatment should prioritize a combination of acute and preventive approaches, with a focus on individualized decision making and patient preferences, as recommended by the most recent guideline from the American College of Physicians 1.
Acute Treatment
For acute treatment, options include:
- Over-the-counter NSAIDs like ibuprofen (400-600mg) or naproxen (500-550mg)
- Prescription triptans such as sumatriptan (50-100mg orally, 6mg subcutaneously, or 20mg nasal spray) or rizatriptan (10mg)
- Newer CGRP antagonists like ubrogepant (50-100mg) or rimegepant (75mg) for severe migraines It is essential to start treatment as soon as possible after the onset of migraine symptoms, using combination therapy to improve efficacy, as suggested by 1 and 1.
Preventive Treatment
For prevention, consider daily medications like:
- Propranolol (80-240mg daily)
- Topiramate (50-200mg daily)
- Amitriptyline (10-150mg at bedtime) Monthly CGRP monoclonal antibody injections such as erenumab (70-140mg), fremanezumab (225mg), or galcanezumab (120mg after 240mg loading dose) offer newer preventive options with fewer side effects, as noted in 1 and 1.
Non-Medication Approaches
Non-medication approaches include:
- Identifying and avoiding triggers (certain foods, stress, irregular sleep)
- Maintaining regular sleep patterns
- Staying hydrated
- Practicing stress management techniques like meditation These treatments work by addressing the neurological and vascular components of migraines, including abnormal brain activity, inflammation, and neurotransmitter imbalances that contribute to pain and associated symptoms, as discussed in 1 and 1.
Key Considerations
- Patient education and involvement in the management plan are crucial, as emphasized in 1
- Regular reevaluation of therapy is necessary to ensure optimal treatment outcomes, as recommended by 1 and 1
- Medication overuse headache is a potential complication of migraine treatment, and patients should be aware of this risk, as noted in 1 and 1
From the FDA Drug Label
The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. In all 3 trials, the percentage of patients achieving headache response 2 and 4 hours after treatment was significantly greater among patients receiving sumatriptan tablets at all doses compared with those who received placebo The estimated probability of achieving an initial headache response over the 4 hours following treatment in pooled Trials 1,2, and 3 is depicted in Figure 1.
Migraine Treatment with Sumatriptan:
- Sumatriptan is effective in the acute treatment of migraine headaches.
- The percentage of patients achieving headache response 2 and 4 hours after treatment is significantly greater with sumatriptan compared to placebo.
- Key doses of sumatriptan used in the trials were 25,50, and 100 mg.
- Sumatriptan also reduces the incidence of migraine-associated symptoms such as nausea, photophobia, and phonophobia. 2
From the Research
Migraine Treatment Options
- Acute treatment for migraine is available in various forms, including triptans, ergot derivatives, and nonsteroidal anti-inflammatory drugs (NSAIDs) 3, 4, 5
- New classes of acute treatment have been developed, such as small-molecule calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan), which do not increase cardiovascular risk 3
- Neuromodulation offers a nonpharmacologic option for acute treatment, with remote electrical neuromodulation showing the strongest evidence 3, 6
Pharmacological Approaches
- Analgesics like aspirin or NSAIDs are effective in treating migraine attacks 4
- Triptans (e.g., sumatriptan, rizatriptan, eletriptan) are highly effective in improving headache, nausea, and photo- and phonophobia 4, 5
- Migraine prophylaxis is recommended for patients with frequent attacks, and substances like beta-blockers, calcium channel blockers, and antiepileptic drugs have proven efficacy 4, 7
Treatment Strategies
- Patient-specific clinical features should guide the selection of an acute medication 5
- Acute medications can be organized into four treatment strategies: acetaminophen-NSAID, triptan, refractory migraine, and strategies for patients with contraindications to vasoconstricting drugs 5
- Rescue medications like dopamine antagonists, combination analgesics, and corticosteroids may be used when usual medications fail 5