From the Guidelines
The most successful treatment for migraines is a multi-faceted approach that includes lifestyle modifications, acute treatment with ibuprofen or triptans, and preventive treatments such as amitriptyline, topiramate, or propranolol, as recommended by the 2020 JAMA Neurology study 1. When treating migraines, it is essential to take a detailed history and make a specific headache diagnosis, advise patients on lifestyle factors and migraine triggers, and counsel them to treat acute migraine early in the attack 1. For acute treatment, ibuprofen is recommended for children and adolescents, while adolescents may also consider sumatriptan, naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral 1. Some key points to consider when treating migraines include:
- Treating acute migraine early in the attack
- Using ibuprofen or triptans for acute treatment
- Considering preventive treatments for frequent or disabling headaches
- Discussing the evidence for and side effects of preventive medications, such as amitriptyline, topiramate, and propranolol
- Identifying and avoiding personal triggers, maintaining consistent sleep patterns, staying hydrated, and practicing stress management techniques to complement medication 1. In terms of preventive treatments, the 2020 JAMA Neurology study recommends discussing the evidence for and side effects of amitriptyline, topiramate, and propranolol with patients and families, as well as considering the teratogenic effects of topiramate and valproate 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for Migraines
- Acute treatment options include triptans, ergot derivatives, and nonsteroidal anti-inflammatory drugs (NSAIDs) 2, 3
- New classes of acute treatment have been developed, including small-molecule calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan) 2
- Neuromodulation offers a nonpharmacologic option for acute treatment, with the strongest evidence for remote electrical neuromodulation 2, 4
- Preventive treatment options are available, but are often underused, with more than 1 in 4 patients with migraines being candidates for preventive therapy 5
Effective Treatment Strategies
- Treatment should be stratified based on the severity of the individual event, with a goal of returning the patient to full function within 2 hours of treatment 5
- A combination of tools, including behavioral management, nonspecific medications, migraine-specific medications, and neuromodulation, can be effective for treating acute attacks 4
- Patient-specific clinical features should guide the selection of an acute medication for an individual patient 3
- Strategies for patients with contraindications to vasoconstricting drugs, such as NSAIDs, combination analgesics, and dopamine antagonists, are available 3
Emerging Treatments
- Novel mechanism-based medications have emerged, expanding the armamentarium of treatments for migraine 6
- Emerging mechanism-based treatments could address unmet challenges in clinical management of migraine 6
- Four neuromodulation devices have been cleared by the US Food and Drug Administration (FDA) for treatment of acute migraine, and three medications with novel mechanisms of action have been FDA approved 4