What is the appropriate acute and preventive management for migraine?

Migraine Management

Acute Treatment

For mild episodic migraine, start with an NSAID (ibuprofen, naproxen, or aspirin) alone or combined with acetaminophen; for moderate-to-severe attacks, use a triptan plus an NSAID or acetaminophen as first-line therapy, treating as early as possible after headache onset 1.

Treatment Algorithm by Severity

Mild Attacks:

• NSAIDs (aspirin, ibuprofen, naproxen, diclofenac, or celecoxib)
• Acetaminophen
• Combination of NSAID + acetaminophen

Moderate-to-Severe Attacks:

• First-line: Triptan + NSAID or acetaminophen (combination therapy improves efficacy) 1
• Available triptans: sumatriptan, rizatriptan, eletriptan, almotriptan, naratriptan, frovatriptan, or zolmitriptan
• Choice depends on route preference and cost

Second-line (if triptan + NSAID fails or contraindicated):

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 1
• Ergot alkaloid: dihydroergotamine

Third-line (if all above fail):

• Lasmiditan (ditan class) 1

Special Situations

Severe nausea/vomiting:

• Use nonoral triptan (subcutaneous sumatriptan, nasal spray formulations)
• Add antiemetic (metoclopramide or domperidone) 1

Emergency Department:

• Prochlorperazine IV (level A - must offer) 2
• Greater occipital nerve blocks (level A - must offer) 2
• Dexketoprofen IV, ketorolac IV, metoclopramide IV, or sumatriptan SC (level B - should offer) 2
• Do NOT use hydromorphone IV (level A - must not offer) 2

Critical Pitfalls to Avoid

Medication overuse headache thresholds:

• NSAIDs: ≥15 days/month
• Triptans: ≥10 days/month 1

Absolutely avoid:

• Opioids for acute migraine treatment 1
• Butalbital-containing compounds 1

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Preventive Treatment

Start with a β-blocker (metoprolol or propranolol), valproate, venlafaxine, or amitriptyline as first-line preventive therapy before considering CGRP-targeted treatments (monoclonal antibodies or gepants), reserving topiramate for patients who fail these options 3.

When to Initiate Prevention

Consider preventive therapy when:

• Severe debilitating headaches despite adequate acute treatment
• Contraindications or intolerance to acute treatments
• Using acute medications more frequently than recommended (approaching overuse thresholds) 3

Preventive Treatment Algorithm

First-line options (choose based on comorbidities and contraindications):

• β-blockers: metoprolol or propranolol
• Antiseizure medication: valproate
• SNRI: venlafaxine
• TCA: amitriptyline 3

Second-line (if first-line fails or not tolerated):

• CGRP antagonists (gepants): atogepant or rimegepant
• CGRP monoclonal antibodies: eptinezumab, erenumab, fremanezumab, or galcanezumab 3

Third-line (if above fail):

• Topiramate (reserved due to higher adverse event frequency despite efficacy) 3

Alternative options (if recommended treatments fail):

• ACE inhibitor: lisinopril
• ARBs: candesartan or telmisartan
• SSRI: fluoxetine 3

For chronic migraine specifically:

• OnabotulinumtoxinA (after multiple oral preventive failures) 4

Implementation Strategy

Dosing approach:

• Start low, titrate slowly to therapeutic dose 3
• Allow adequate trial duration: generally 2-3 months before switching 3
• Improvement may be gradual over first few weeks 3

Monitoring:

• Use headache diary to track efficacy and identify analgesic overuse 3
• Switch if inadequate response after reasonable trial or earlier if adverse events occur 3

Cost Considerations

The 2025 ACP guidelines explicitly prioritize cost-effectiveness, recommending older generic medications (β-blockers, valproate, venlafaxine, amitriptyline) before newer expensive CGRP-targeted therapies, despite similar efficacy profiles 3. This reflects real-world practice where insurance often requires step therapy.

Pregnancy and Lactation

In people of childbearing potential, pregnant, or breastfeeding individuals, discuss adverse effects of all pharmacologic treatments during pregnancy and lactation before initiating therapy 1, 3. Many standard preventive medications (valproate, topiramate) carry significant teratogenic risks.

Lifestyle Modifications

Emphasize alongside pharmacotherapy:

• Adequate hydration
• Regular, sufficient sleep
• Regular physical activity (moderate-to-intense aerobic exercise preferred)
• Stress management (relaxation techniques, mindfulness)
• Weight loss if overweight/obese
• Identify and modify individual migraine triggers 1