What are the recommended management strategies for migraine headaches?

From the Guidelines

Effective migraine management requires a comprehensive approach combining preventive and acute treatment strategies, with the most recent guidelines from 2025 recommending the use of triptans and NSAIDs or acetaminophen for acute treatment, and preventive medications such as beta-blockers or topiramate for patients experiencing frequent migraines 1.

Key Recommendations

• For acute treatment, consider using a triptan and an NSAID or acetaminophen, as recommended by the American College of Physicians 1.
• For moderate to severe acute episodic migraine headache, consider using the ditan lasmiditan in nonpregnant outpatient adults who do not tolerate or have inadequate response to other pharmacologic treatments 1.
• Do not use opioids or butalbital for the treatment of acute episodic migraine, as they are not recommended by the guidelines 1.
• Consider using a nonoral triptan and an antiemetic in people having severe nausea or vomiting, as this can help alleviate symptoms 1.

Preventive Strategies

• Counsel patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy to improve efficacy 1.
• If the episodic migraine occurs frequently or treatment does not provide an adequate response, consider adding preventive medications such as beta-blockers or topiramate 1.
• Highlight the importance of lifestyle modifications, including staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, engaging in regular physical activity, managing stress with relaxation techniques or mindfulness practices, and pursuing weight loss for those who are overweight or obese 1.

Important Considerations

• Be aware of medication overuse headache, which is a potential complication of migraine treatment, and counsel patients on the risks and symptoms 1.
• Prescribe less costly recommended medications, as this can help improve adherence and outcomes 1.
• Consider the potential benefits and risks of preventive medications, including teratogenic effects, and discuss these with patients and families 1.

From the FDA Drug Label

The use of sumatriptan tablets is contraindicated in patients with CAD and those with Prinzmetal’s variant angina. Rizatriptan benzoate should not be given to patients with ischemic or vasospastic coronary artery disease. For patients with multiple cardiovascular risk factors who have a negative cardiovascular evaluation, consider administering the first dose of sumatriptan tablets in a medically supervised setting and performing an electrocardiogram (ECG) immediately following administration of sumatriptan tablets The estimated probability of achieving an initial headache response within 2 hours following treatment in pooled Studies 1,2,3, and 4 is depicted in Figure 1 The percentage of patients achieving the primary efficacy endpoint of no headache pain at 2 hours after treatment was significantly greater in patients who received rizatriptan benzoate orally disintegrating tablets, compared with those who received placebo (33% vs. 24%)

The recommended management strategies for migraine headaches include:

• Triptans: Sumatriptan and rizatriptan are effective for the acute treatment of migraine headaches, but are contraindicated in patients with CAD, Prinzmetal’s variant angina, and those with a history of stroke or TIA.
• Cardiovascular evaluation: Patients with multiple cardiovascular risk factors should undergo a cardiovascular evaluation prior to receiving triptans.
• Medically supervised setting: The first dose of triptans should be administered in a medically supervised setting for patients with multiple cardiovascular risk factors.
• ECG monitoring: An ECG should be performed immediately following the administration of triptans in patients with multiple cardiovascular risk factors.
• Dose and administration: The dose and administration of triptans should be individualized based on the patient's response and medical history.
• Concomitant medications: The use of triptans with other medications, such as SSRIs, SNRIs, and MAO inhibitors, should be avoided due to the risk of serotonin syndrome 2, 3, 3.

From the Research

Migraine Headache Management Strategies

Migraine headache management involves a combination of lifestyle modifications, preventive therapies, and acute treatments. The following are some recommended management strategies for migraine headaches:

• Lifestyle modifications: Maintaining a regular lifestyle, with regular sleep, meals, exercise, and management of stress, perhaps through relaxation techniques or other ways that are sensible for them 4.
• Preventive therapies: Prescription medications, nutraceuticals, neurostimulation, and behavioral therapy can be used to prevent migraine attacks. Treatments with the most favorable profiles include amitriptyline, beta-blockers, biofeedback, candesartan, coenzyme Q10, cognitive-behavioral therapy, magnesium citrate, onabotulinumtoxinA, relaxation therapy, riboflavin, and topiramate 5.
• Acute treatments: Acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine can be used to treat acute migraine attacks. Migraine-specific treatments, such as triptans, gepants, and lasmiditan, can also be used to eliminate pain in patients who do not respond to other treatments 6, 7.

Preventive Therapy

Preventive therapy is recommended for patients who experience frequent migraine attacks or have a high degree of migraine-associated disability. The decision to recommend preventive therapy should consider the frequency of migraine attacks and headaches, extent of migraine-associated disability, frequency of using acute migraine treatments, and patient preferences 5.

• Beta-adrenoceptor blockers, flunarizine, topiramate, and valproic acid are considered first-line treatments for migraine prophylaxis 4.
• Other options, such as amitriptyline, methysergide, and pizotifen, may be considered for patients who do not respond to first-line treatments or have contraindications to their use 4.

Acute Treatment

Acute treatment for migraine headaches typically involves the use of analgesics, nonsteroidal anti-inflammatory drugs, and migraine-specific treatments, such as triptans and gepants.

• The choice of acute treatment should be based on the patient's individual needs and medical history, as well as the severity and frequency of their migraine attacks 6, 7.
• Patients with contraindications to vasoconstricting drugs, such as those with cardiovascular disease, may require alternative treatments, such as NSAIDs or combination analgesics 6.