From the Guidelines
First-line migraine treatment typically involves nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-600mg) or naproxen sodium (500-550mg), or the combination agent acetaminophen plus aspirin plus caffeine, taken at the first sign of headache, as recommended by studies 1. These medications work best when taken early in an attack. For optimal results, combine medication with:
- Rest in a quiet, dark room
- Apply cold compresses to the forehead
- Stay hydrated
- Consider caffeine (contained in some combination medications like Excedrin Migraine) which can enhance pain relief These treatments work by reducing inflammation, constricting dilated blood vessels, and blocking pain pathways in the brain. If over-the-counter options aren't effective, prescription triptans or gepants may be necessary. For frequent migraines (more than 4 days per month), preventive treatment should be considered rather than relying solely on acute treatments. Triptans such as sumatriptan (50-100mg orally, 6mg subcutaneously, or 20mg nasal spray) are also considered first-line, especially for moderate to severe migraines. It is essential to educate migraine sufferers about the control of acute attacks and preventive therapy and engage them in the formulation of a management plan, as emphasized in the studies 1. However, the most recent and highest quality study 1 should be prioritized, which recommends NSAIDs as the first-line therapy for most migraine sufferers.
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. 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
First-line migraine treatment with sumatriptan (PO) can be initiated with a dose of 25 mg, 50 mg, or 100 mg. The choice of dose should be based on the individual patient's response and tolerance to the medication.
- A second dose may be administered at least 2 hours after the first dose if the migraine has not resolved or returns after a transient improvement.
- The maximum daily dose is 200 mg in a 24-hour period 2 2.
From the Research
First-Line Treatment for Migraine
- Over-the-counter medications such as acetaminophen, ibuprofen, naproxen, and aspirin are considered first-line treatments for mild-to-moderate migraine attacks 3
- Acetaminophen 1000 mg alone is an effective treatment for acute migraine headaches, and the addition of 10 mg metoclopramide gives short-term efficacy equivalent to oral sumatriptan 100 mg 4
- Acetaminophen and nonsteroidal anti-inflammatory drugs are first-line treatments for mild to moderate migraines, whereas triptans are first-line treatments for moderate to severe migraines 5
Treatment Strategies
- A stratified treatment approach can help ensure that migraine treatment is cost-effective 5
- The administration of acute medications should follow the concept of "stratified care" 6
- For mild to moderate migraine attacks, oral NSAIDs are the first choice; with oral aspirin, combination analgesics, intravenous/intramuscular NSAIDs as alternatives 6
- For moderate to severe attacks, oral or nasal spray triptans and ergotamine/caffeine compounds are recommended and should be administered in the early stage of migraine attacks 6
Medication Options
- Triptans, acetaminophen, and non-steroid anti-inflammation drugs (NSAID) such as aspirin, diclofenac, ibuprofen, and naproxen are considered effective for acute migraine attacks 6
- Sumatriptan/naproxen and combined acetaminophen/aspirin/caffeine are also considered effective 6
- Antiemetics can be used as supplement to alleviate nausea and vomiting 6