From the Guidelines
The most effective treatment for migraines is a personalized approach that considers the patient's preferences, severity of symptoms, and response to previous treatments, with a focus on combination therapy, such as a triptan with an NSAID or acetaminophen, as recommended by the American College of Physicians 1. When treating mild episodic migraine headache, consider using an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen.
- For moderate to severe acute episodic migraine headache, CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) may be effective options for nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen 1.
- The ditan lasmiditan can be considered for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to all other pharmacologic treatments included in the guideline 1.
- It is essential to counsel patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy to improve efficacy, and to be aware of medication overuse headache, a potential complication of migraine treatment 1. Key considerations in treating migraines include:
- Avoiding opioids or butalbital for the treatment of acute episodic migraine
- Using a nonoral triptan and an antiemetic in people having severe nausea or vomiting
- Discussing the adverse effects of pharmacologic treatments during pregnancy and lactation in people of childbearing potential and in those who are pregnant or breastfeeding
- Considering the addition of preventive medications if the episodic migraine occurs frequently or treatment does not provide an adequate response 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 results from the 3 controlled clinical trials are summarized in Table 2. Table 2 Percentage of Patients With Headache Response (Mild or No Headache) 2 and 4 Hours Following Treatment Sumatriptan Tablets 25 mg 2 hr 4 hr Sumatriptan Tablets 50 mg 2 hr 4 hr Sumatriptan Tablets 100 mg 2 hr 4 hr Placebo 2 hr 4 hr
The best treatment for migraines, based on the provided drug label, is sumatriptan tablets at doses of 25 mg, 50 mg, or 100 mg.
- The 50 mg and 100 mg doses showed a statistically significant greater percentage of patients with headache response at 2 and 4 hours in one of the trials compared to the 25 mg dose.
- However, there were no statistically significant differences between the 50 mg and 100 mg dose groups in any trial 2. Key points to consider when treating migraines with sumatriptan include:
- Headache response: defined as a reduction in headache severity from moderate or severe pain to mild or no pain
- Associated symptoms: such as nausea, photophobia, and phonophobia were also assessed and showed a lower incidence at 2 and 4 hours following administration of sumatriptan tablets compared with placebo.
From the Research
Migraine Treatment Options
The treatment of migraines can be approached through various methods, including pharmacological and non-pharmacological interventions.
- Pharmacological Treatments:
- First-line agents for migraine prevention include propranolol, timolol, amitriptyline, divalproex, sodium valproate, and topiramate 3, 4, 5, 6.
- Gabapentin and naproxen sodium have shown fair evidence of effectiveness in migraine prevention 3, 4, 6.
- Botulinum toxin has demonstrated fair effectiveness, but further studies are needed to define its role in migraine prevention 3.
- Non-Pharmacological Treatments:
- Non-pharmacological treatments such as relaxation techniques, bio-feedback, cognitive behavioral therapy, and acupuncture are supported by some evidence, but require more specialist time or technical devices 4.
Considerations for Treatment
When choosing a treatment for migraines, several factors should be considered, including:
- Efficacy: The effectiveness of the treatment in preventing migraines.
- Co-morbidity: The presence of other health conditions that may interact with the treatment.
- Side Effects: The potential side effects of the treatment and how they may impact the patient.
- Availability and Cost: The availability and cost of the treatment, which can impact accessibility.
Specific Treatments
Some specific treatments that have been studied for migraine prevention include:
- Topiramate: Topiramate has been shown to be effective in reducing migraine frequency and acute medication use, and improving quality of life 5, 7.
- Beta-Blockers: Beta-blockers, such as propranolol and timolol, are effective for migraine attack prophylaxis, but may be associated with dizziness and fatigue, and are contraindicated in patients with certain co-morbidities 5.
- Antiepileptic Drugs: Antiepileptic drugs, such as divalproex sodium, are effective for migraine exacerbation prophylaxis, but may have associated side effects 5.