What is the best initial treatment for migraine headache?

From the Guidelines

The best initial treatment for a migraine is a combination of a nonsteroidal anti-inflammatory drug (NSAID) like ibuprofen (400-600mg) or naproxen sodium (500-550mg) along with an antiemetic such as metoclopramide (10mg) if nausea is present, taken at the first sign of migraine symptoms. This approach is supported by the most recent and highest quality study 1, which recommends considering treating mild episodic migraine headache with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen.

Key Considerations

• For moderate to severe migraines, triptans such as sumatriptan (50-100mg orally) may be more effective and should be taken early in the attack 2.
• Patients should rest in a quiet, dark room as light and sound can worsen symptoms.
• Staying hydrated and applying cold compresses to the forehead or neck may provide additional relief.
• If over-the-counter medications don't provide relief within two hours or if migraines occur frequently (more than 4 days per month), consulting a healthcare provider for prescription options or preventive treatments is recommended.

Additional Treatment Options

• CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) may be considered for moderate to severe acute episodic migraine headache in 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 may be considered to treat 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 this guideline 1.

Important Warnings

• Opioids or butalbital should not be used for the treatment of acute episodic migraine 1.
• Patients should be aware of medication overuse headache, which is a potential complication of migraine treatment 1.

From the FDA Drug Label

The recommended dose of sumatriptan tablets is 25 mg, 50 mg, or 100 mg. Doses of 50 mg and 100 mg may provide a greater effect than the 25 mg dose, but doses of 100 mg may not provide a greater effect than the 50 mg dose. The best initial treatment for a migraine is sumatriptan tablets at a dose of 25 mg, 50 mg, or 100 mg 3.

• The dose of 50 mg or 100 mg may be more effective than 25 mg, but 100 mg may not be more effective than 50 mg.
• The maximum daily dose is 200 mg in a 24-hour period 4.

From the Research

Initial Treatment for Migraine

The best initial treatment for a migraine can vary depending on the individual and the severity of the symptoms. However, based on the available evidence, the following options can be considered:

• Ibuprofen: Studies have shown that ibuprofen is an effective treatment for acute migraine headaches, providing pain relief in about half of sufferers 5. The recommended dose is 400 mg, which has been shown to be more effective than 200 mg.
• Combination therapies: Combining triptans with non-steroidal anti-inflammatory drugs (NSAIDs) has been shown to be more effective than using single agents alone 6. For example, the combination of sumatriptan and naproxen sodium has been shown to offer improved 2-hour and 24-hour benefits over monotherapy with each option.
• Metoclopramide: Metoclopramide, an antiemetic, has also been shown to have pain-relieving effects for migraine and can be considered as a first-line medication for migraine attacks in emergency department settings 7.
• Over-the-counter medications: 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 8.

Comparison of Treatments

The available evidence suggests that:

• Ibuprofen 400 mg is more effective than 200 mg for 2-hour headache relief 5.
• The combination of sumatriptan and naproxen sodium is more effective than monotherapy with each option 6.
• Metoclopramide can be considered as a first-line medication for migraine attacks in emergency department settings, especially when triptans are contraindicated or have severe side effects 7.
• Over-the-counter medications are an important component of migraine therapy and can be considered as a first-line treatment for most migraineurs 8.

Efficacy and Tolerability

The available evidence suggests that:

• Ibuprofen is well-tolerated, with adverse events mostly mild and transient 5.
• The combination of sumatriptan and naproxen sodium has been shown to be well-tolerated, with no difference in tolerability between the combination and monotherapy with each option 6.
• Metoclopramide has been shown to be well-tolerated, with no significant difference in adverse events compared to sumatriptan 9, 7.