What are the recommended acute and preventive medications for treating migraines in adults without contraindications?

Migraine Medications: Acute and Preventive Treatment

Acute Treatment

Start with an NSAID (ibuprofen, naproxen, diclofenac, aspirin, or celecoxib) or acetaminophen at adequate doses; if insufficient pain relief occurs, add a triptan to the NSAID (or to acetaminophen if NSAIDs are contraindicated). 1

Stepwise Approach to Acute Treatment

For Mild Episodic Migraine:

• Use NSAID monotherapy, acetaminophen, or their combination 1
• Ensure adequate dosing before escalating therapy

For Moderate to Severe Episodic Migraine:

1. First-line: Combination therapy - Triptan + NSAID provides the greatest net benefit (moderate-certainty evidence) 1

   • Specific triptans: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan
   • Specific NSAIDs: aspirin, celecoxib, diclofenac, ibuprofen, or naproxen
   • Alternative: Triptan + acetaminophen (when NSAIDs contraindicated) 1

2. Second-line options (if combination therapy fails or is not tolerated):

   • CGRP antagonists-gepants: rimegepant, ubrogepant, or zavegepant 1
   • Dihydroergotamine (ergot alkaloid) 1

3. Third-line option:

   • Lasmiditan (ditan) - reserve for patients who fail all other treatments 1

Critical Contraindications:

• Never use opioids or butalbital for acute episodic migraine 1

Special Situations

Severe nausea/vomiting:

• Use nonoral triptan formulations (nasal spray, subcutaneous injection) plus antiemetic 1

Treatment timing:

• Begin treatment as soon as possible after migraine onset 1
• Early treatment with combination therapy improves efficacy

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Preventive Treatment

For episodic migraine prevention, initiate monotherapy with propranolol (beta-blocker), topiramate (antiseizure medication), or amitriptyline (tricyclic antidepressant) as first-line options. 2

First-Line Preventive Medications (Episodic Migraine)

Traditional oral agents:

• Beta-blockers: Propranolol or metoprolol 3, 4
• Antiseizure medications: Topiramate (reduces migraine days by 1.4/month vs placebo) or valproate 3, 4
• Tricyclic antidepressants: Amitriptyline (reduces migraine days by 1.2/month vs placebo) 4
• Calcium channel blockers: Flunarizine 3

Newer CGRP-targeted therapies (considered first-line by some guidelines, second-line by others based on cost/access):

• Monoclonal antibodies: Eptinezumab, erenumab, fremanezumab, galcanezumab (reduce migraine days by 0.7-3.8/month) 5, 4
• Oral gepants: Atogepant or rimegepant (reduce migraine days by 0.7-2.4/month) 5, 4

Chronic Migraine Prevention

First-line options:

• Topiramate 3
• Flunarizine 3
• OnabotulinumtoxinA (after failure of multiple oral preventives) 3
• CGRP monoclonal antibodies 3, 4

Indications to Start Preventive Treatment

Initiate prevention when:

• Headache frequency ≥4 days per month 3
• Profound disability from attacks
• Failure of or contraindication to acute therapies
• Complicated migraine with debilitating auras
• Migrainous brain infarction 3

Treatment Principles

Dosing strategy for oral medications:

• "Start low and go slow" 3
• Titrate to therapeutic dose if tolerated
• Allow adequate trial duration (typically 2-3 months)

Duration of preventive therapy:

• Episodic migraine: Consider tapering after 3-6 months of sustained improvement 3
• Chronic migraine: Consider tapering after 6-12 months of sustained improvement 3

If initial preventive fails:

• Try another medication within the same class (patients may respond differently) 1
• Consider CGRP-targeted therapies if traditional oral agents fail 4

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Critical Warnings

Medication Overuse Headache

• Occurs with ≥15 days/month of NSAID or acetaminophen use 1
• Occurs with ≥10 days/month of triptan use 1
• Defined as headache on ≥15 days/month for ≥3 months due to acute medication overuse
• Education about not overusing acute medications is essential 3

Pregnancy and Lactation

• Discuss adverse effects of all pharmacologic treatments with people of childbearing potential 1
• Most migraine medications have limited safety data in pregnancy
• Treatment decisions require careful risk-benefit analysis

Cost Considerations

• Prescribe less costly recommended medications when appropriate 1
• CGRP-targeted therapies are significantly more expensive than traditional oral preventives
• Patient preference data shows cost is a major factor in treatment decisions 1

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Lifestyle Modifications (Essential Adjunct)

Counsel all patients on:

• Adequate hydration
• Regular meals
• Sufficient and consistent sleep
• Regular moderate-to-intense aerobic exercise
• Stress management (relaxation techniques, mindfulness)
• Weight loss if overweight/obese
• Identify and modify personal migraine triggers 1