What are the treatment options for migraine?

From the Guidelines

Migraine treatment should prioritize acute and preventive options, with a focus on individualized therapy and lifestyle modifications, as recommended by the most recent guidelines from the American College of Physicians 1.

Acute Treatment Options

• Over-the-counter medications like ibuprofen (400-600mg), naproxen (500-550mg), or acetaminophen (1000mg) can help mild attacks.
• Prescription options include triptans such as sumatriptan (50-100mg orally, 6mg subcutaneously, or 20mg nasal spray) or rizatriptan (10mg), which work by constricting blood vessels and blocking pain pathways.
• New gepants (rimegepant, ubrogepant) and ditans (lasmiditan) are alternatives for those who can't take triptans.
• For severe attacks, dihydroergotamine or anti-nausea medications like metoclopramide (10mg) may be added.

Preventive Treatment Options

• Preventive treatment is recommended for frequent migraines (4+ monthly) and includes beta-blockers (propranolol 80-240mg daily), antiseizure medications (topiramate 50-200mg daily), antidepressants (amitriptyline 10-50mg nightly), and CGRP monoclonal antibodies (monthly or quarterly injections).
• Botox injections every 12 weeks can help chronic migraine.

Lifestyle Modifications

• 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 can help reduce migraine frequency and severity.
• Identifying and avoiding specific migraine triggers, such as certain foods or stressors, can also be beneficial.

Key Recommendations

• Begin treatment of migraine headache as soon as possible after its onset, using combination therapy (such as a triptan with an NSAID or acetaminophen) to improve efficacy 1.
• Consider using a nonoral triptan and an antiemetic in people having severe nausea or vomiting.
• Counsel patients to be aware of medication overuse headache, which is a potential complication of migraine treatment.

From the FDA Drug Label

The primary efficacy endpoint was the change from baseline in monthly migraine days at month 3 Secondary endpoints included the achievement of a ≥ 50% reduction from baseline in monthly migraine days ("≥ 50% MMD responders"), the change from baseline in monthly acute migraine-specific medication days at month 3, Patients were allowed to use acute headache treatments including migraine-specific medications (i.e., triptans, ergotamine derivatives) and NSAIDs during the study.

The treatment options for migraine include:

• Migraine-specific medications such as triptans and ergotamine derivatives
• NSAIDs
• Preventive treatment with erenumab (SQ), which has shown statistically significant improvements in reducing monthly migraine days compared to placebo 2

From the Research

Treatment Options for Migraine

• Migraine is a highly disabling condition that can be treated with various medications, including triptans, non-steroidal anti-inflammatory drugs (NSAIDs), and other options 3, 4, 5.
• Sumatriptan, a triptan, is an effective abortive treatment for migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability 3, 6.
• The combination of sumatriptan and naproxen is also effective in treating migraine attacks, with a greater effect than either medication alone 4.
• Other treatment options for migraine include:
  • NSAIDs, such as ibuprofen and acetaminophen, which are effective for acute treatment but may have adverse effects such as gastrointestinal upset and renal symptoms 5.
  • Beta-blockers, such as propranolol and timolol, which are effective for migraine prevention but may have adverse effects such as dizziness and fatigue 5.
  • Antiepileptic drugs, such as topiramate and divalproex sodium, which are effective for migraine prevention but may have adverse effects such as dizziness and fatigue 5.
  • Antidepressants, such as venlafaxine and amitriptyline, which may be effective for migraine prevention but may have adverse effects such as dizziness and fatigue 5.
• Combining sumatriptan with metoclopramide may provide relief in some migraineurs who fail to achieve adequate relief with a triptan alone 7.

Acute Treatment of Migraine

• Sumatriptan is effective in relieving migraine headache and associated symptoms, including nausea, photophobia, and phonophobia 3, 6.
• The combination of sumatriptan and naproxen is effective in treating migraine attacks, with a greater effect than either medication alone 4.
• Treating early, during the mild pain phase, may give significantly better results than treating established attacks with moderate or severe pain intensity 3, 4.

Prevention of Migraine

• Beta-blockers, such as propranolol and timolol, are effective for migraine prevention but may have adverse effects such as dizziness and fatigue 5.
• Antiepileptic drugs, such as topiramate and divalproex sodium, are effective for migraine prevention but may have adverse effects such as dizziness and fatigue 5.
• Antidepressants, such as venlafaxine and amitriptyline, may be effective for migraine prevention but may have adverse effects such as dizziness and fatigue 5.