Headache Treatment
For acute episodic migraine, start with an NSAID (ibuprofen 400-800mg or naproxen 275-550mg) or acetaminophen (1000mg), and if inadequate relief occurs, immediately add a triptan to the NSAID or acetaminophen—this combination therapy should be initiated as early as possible during the attack for optimal efficacy. 1
Acute Treatment Algorithm
Mild to Moderate Migraine
- First-line: NSAIDs (ibuprofen, naproxen, aspirin) or acetaminophen 1000mg 1
- Important: Acetaminophen alone at doses <1000mg is ineffective for migraine 2
- Combination products with aspirin, acetaminophen, and caffeine are effective 2
Moderate to Severe Migraine
- First-line: Triptan + NSAID combination therapy 1
Treatment Escalation for Inadequate Response
If triptan + NSAID/acetaminophen combination fails:
- Second-line: CGRP antagonists (gepants: rimegepant, ubrogepant, zavegepant) or dihydroergotamine 1
- Third-line: Lasmiditan (ditan) for patients who fail all other treatments 1
Special Circumstances
- With nausea/vomiting: Use non-oral triptan (subcutaneous, intranasal, or dissolvable wafer) + antiemetic (metoclopramide or prochlorperazine) 1, 2
- Severe refractory migraine: Parenteral ketorolac 60mg IM (duration ~6 hours) 2
Critical Contraindications and Warnings
Absolutely avoid opioids and butalbital-containing medications for acute migraine treatment—they cause medication overuse headache, dependency, and eventual loss of efficacy without improving morbidity or quality of life 1
Triptan Contraindications
- Ischemic vascular disease
- Vasospastic coronary disease
- Uncontrolled hypertension
- Significant cardiovascular disease 2
Gepants and Lasmiditan Advantages
Unlike triptans and ergots, gepants and ditans lack vascular contraindications, making them suitable for patients with cardiovascular risk factors 1
Medication Overuse Headache Prevention
Monitor frequency thresholds carefully:
- NSAIDs: ≥15 days/month triggers medication overuse headache 1
- Triptans: ≥10 days/month triggers medication overuse headache 1
- Ergotamine: High risk for rebound headaches and increased headache frequency 2
Timing and Efficacy Principles
Initiate treatment immediately at headache onset—early administration significantly improves efficacy and functional restoration 2, 1
If a patient fails one triptan, try a different triptan within the class before abandoning this approach—individual response varies significantly 2. Test each medication for 2-3 headache episodes before determining inefficacy 2.
Preventive Therapy Indications
Consider preventive medications when:
- Episodic migraine occurs frequently (>2 headaches/week) 2
- Acute treatment provides inadequate response 1
- Patient experiences ≥4 disabling attacks per month 3
First-line preventive agents:
- Beta-blockers (propranolol)
- Antiseizure medications (topiramate, valproate)
- Tricyclic antidepressants (amitriptyline 50-100mg) 3, 4
- CGRP monoclonal antibodies (newer guidelines) 4
For chronic migraine (≥15 headache days/month): OnabotulinumtoxinA injections reduce headache days by 1.8 days/month vs. placebo 3
Non-Pharmacologic Measures
Essential lifestyle modifications that reduce migraine frequency:
- Maintain hydration and regular meal schedule
- Secure consistent sleep (7-9 hours)
- Engage in moderate-to-intense aerobic exercise regularly
- Practice stress management (relaxation techniques, mindfulness)
- Identify and avoid individual migraine triggers 1
Pregnancy and Lactation Considerations
Discuss adverse effects of all pharmacologic treatments with patients of childbearing potential before prescribing—ergot alkaloids have oxytocic properties and are contraindicated in pregnancy 1, 2
Cost Considerations
Prescribe less costly recommended medications when clinically equivalent—generic NSAIDs and older triptans (sumatriptan, naratriptan) provide excellent efficacy at lower cost than newer gepants and ditans 1