What is the treatment for migraines?

From the Guidelines

Migraine treatment should prioritize acute and preventive approaches, with a focus on early treatment and lifestyle modifications to reduce symptoms and disability, as recommended by the most recent guidelines 1. The treatment of migraines involves both acute and preventive strategies. For acute treatment, over-the-counter pain relievers like ibuprofen (400-600mg) or aspirin (650-1000mg) can help mild attacks, as supported by evidence from 1. Prescription options include triptans such as sumatriptan (25-100mg orally) or rizatriptan (5-10mg), which work by constricting blood vessels and blocking pain pathways.

Key Considerations

• For severe migraines, anti-nausea medications like metoclopramide (10mg) may be added, as suggested by 1.
• Preventive treatment is recommended for frequent migraines (4+ monthly) and includes beta-blockers like propranolol (80-240mg daily), antidepressants such as amitriptyline (10-150mg nightly), or anticonvulsants like topiramate (25-200mg daily), as recommended by 1 and 1.
• Non-medication approaches are also important, including:
  • Identifying and avoiding triggers (certain foods, stress, irregular sleep)
  • Maintaining regular sleep patterns
  • Staying hydrated
  • Practicing stress management techniques like meditation

Treatment Approach

The most effective treatment approach is to start early in an attack, with a focus on reducing symptoms and disability, as recommended by 1. During an attack, resting in a dark, quiet room can help reduce symptoms. Treatment should be started early in an attack for best results, and preventive medications typically need 2-3 months to show full effectiveness.

Preventive Treatment

Preventive treatment options, such as CGRP antagonists like erenumab (70-140mg monthly injection), represent newer preventive options, as discussed in 1 and 1. It is essential to discuss the evidence for and side effects of amitriptyline combined with cognitive behavioral therapy, topiramate, and propranolol for migraine prevention, as well as the teratogenic effects of topiramate and valproate, and advise patients to use effective birth control methods and take folate, as recommended by 1.

From the FDA Drug Label

CLINICAL PHARMACOLOGY 12. 1 Mechanism of Action Sumatriptan binds with high affinity to human cloned 5-HT1B/1D receptors 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, which result in cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release.

12 CLINICAL PHARMACOLOGY 12. 1 Mechanism of Action Eletriptan binds with high affinity to 5-HT1B, 5-HT1D and 5-HT1F receptors, has modest affinity for 5-HT1A, 5-HT1E, 5-HT2B and 5-HT7 receptors. Migraines are likely due to local cranial vasodilatation and/or to the release of sensory neuropeptides (vasoactive intestinal peptide, substance P and calcitonin gene-related peptide) through nerve endings in the trigeminal system The therapeutic activity of eletriptan hydrobromide for the treatment of migraine headache is thought to be due to the agonist effects at the 5-HT1B/1D receptors on intracranial blood vessels (including the arterio-venous anastomoses) and sensory nerves of the trigeminal system which result in cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release.

The treatment for migraines includes sumatriptan and eletriptan, which are both agonists of the 5-HT1B/1D receptors. These medications work by causing cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release.

• Sumatriptan is available in oral and subcutaneous forms, with a bioavailability of approximately 15% 2.
• Eletriptan is available in oral form, with a bioavailability of approximately 50% 3. Key points to consider when treating migraines with these medications include:
• Dosing: The dosage of sumatriptan and eletriptan may vary depending on the patient and the severity of the migraine.
• Administration: Sumatriptan can be administered orally or subcutaneously, while eletriptan is administered orally.
• Side effects: Both medications may cause elevation in blood pressure, including hypertensive crisis, and should be used with caution in patients with a history of hypertension.

From the Research

Treatment Options for Migraines

• Triptans, such as sumatriptan, are the first-line treatment for moderate-to-severe migraine headaches 4, 5, 6, 7
• Acetaminophen and nonsteroidal anti-inflammatory drugs are first-line treatments for mild to moderate migraines 5
• Antiemetics and ergot alkaloids are recommended for use as second- or third-line therapy for select patients or for those with refractory migraine 5, 8
• New classes of acute treatment, including the small-molecule calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan), are available for migraine treatment 7

Administration and Formulations

• Sumatriptan is available in different formulations, including subcutaneous, intranasal, transdermal, oral, and suppository options 4
• The fastest and most complete migraine relief occurs with subcutaneous dosing, while oral administration is generally preferred by patients 4
• Intranasal, transdermal, and suppository formulations are options for patients with nausea who do not require or prefer to avoid subcutaneous administration 4

Treatment Principles

• Taking medication early in an attack and using a stratified treatment approach can help ensure that migraine treatment is cost-effective 5
• Patients should use an attack-based treatment approach for their migraine attacks to balance the speed of relief, efficacy, and tolerability 4
• Switching within and between classes, using the maximum allowed dose, using combination therapy, and counseling patients to treat early are all strategies that may improve patient response to acute treatment 7