What are the treatment options for migraine headaches?

From the Guidelines

Migraine headache treatment should prioritize acute treatment with NSAIDs, acetaminophen, or combination therapy, and consider preventive medications for frequent episodes, as recommended by the most recent guideline from the American College of Physicians 1.

Acute Treatment

For acute treatment, the following options can be considered:

• Over-the-counter medications like ibuprofen (400-600mg), naproxen (500-550mg), or acetaminophen (1000mg) can be effective if taken early in an attack.
• Prescription options include triptans such as sumatriptan (50-100mg orally, or 6mg subcutaneously), rizatriptan (10mg), or zolmitriptan (2.5-5mg), which work by constricting blood vessels and blocking pain pathways.
• For severe migraines, newer CGRP antagonists like ubrogepant (50-100mg) or rimegepant (75mg) may help, especially for those who cannot take triptans.

Preventive Treatment

For prevention, if migraines occur more than 4 times monthly, consider:

• Propranolol (80-240mg daily) 1
• Topiramate (50-200mg daily) 1
• Amitriptyline (10-150mg nightly) 1
• Monthly CGRP monoclonal antibodies like erenumab (70-140mg) or fremanezumab (225mg) 1

Non-Medication Approaches

Non-medication approaches are also important:

• Identify and avoid triggers (certain foods, stress, irregular sleep)
• Maintain regular sleep patterns
• Stay hydrated
• Practice stress management techniques like meditation
• During an attack, resting in a dark, quiet room and applying cold compresses can provide relief.

Key Considerations

• Do not use opioids or butalbital for the treatment of acute episodic migraine 1.
• Consider using a nonoral triptan and an antiemetic in people having severe nausea or vomiting 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.

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 Headache Treatment: Sumatriptan tablets are effective in the acute treatment of migraine headaches.

• The medication has been shown to be effective at doses of 25,50, and 100 mg, with a significant percentage of patients achieving headache response 2 and 4 hours after treatment.
• The results from the 3 controlled clinical trials demonstrate that sumatriptan tablets are more effective than placebo in treating migraine headaches 2.
• Sumatriptan 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 2.

From the Research

Migraine Headache Treatment Options

• Migraine headaches are a neurologic disorder characterized by attacks of moderate to severe throbbing headache, and the primary goals of acute migraine therapy are to reduce attack duration and severity 3.
• Current evidence-based therapies for acute migraine attacks include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, NSAID-triptan combinations, dihydroergotamine, non-opioid combination analgesics, and several anti-emetics 3, 4.
• Over-the-counter medications, such as acetaminophen, ibuprofen, naproxen, and aspirin, have shown strong efficacy when used as first-line treatments for mild-to-moderate migraine attacks 3, 5.

Efficacy of Specific Treatments

• Ibuprofen is an effective treatment for acute migraine headaches, providing pain relief in about half of sufferers, but complete relief from pain and associated symptoms for only a minority 5.
• The combination of a triptan plus a non-steroidal anti-inflammatory drug (NSAID) has demonstrated better efficacy in treating migraine attacks 6.
• Triptans, such as sumatriptan, are first-line treatments for moderate to severe migraines, but may be expensive 4.
• Gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, such as rimegepant or ubrogepant, can eliminate headache symptoms for 2 hours in 20% of patients 7.

Treatment Principles

• Taking medication early in an attack and using a stratified treatment approach can help ensure that migraine treatment is cost-effective 4.
• Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder, and treated accordingly 7.
• Patients not responsive to initial treatments may require migraine-specific treatments, including triptans or gepants, but should be aware of potential adverse effects and contraindications 5, 7.