What are the treatment options for migraine headaches?

From the Guidelines

Migraine headaches can be effectively treated with a combination of acute and preventive medications, as well as lifestyle modifications, with the goal of reducing morbidity, mortality, and improving quality of life. For acute treatment, over-the-counter pain relievers like ibuprofen (400-600mg), naproxen (500-550mg), or acetaminophen (1000mg) can help mild migraines, as recommended by the American College of Physicians 1. For moderate to severe migraines, triptans such as sumatriptan (50-100mg orally, 6mg subcutaneously, or 20mg nasal spray) are effective and work by constricting blood vessels and blocking pain pathways, and should be taken at the first sign of migraine for best results 1. Some key points to consider when treating migraine headaches include:

• Using a nonoral triptan and an antiemetic in people having severe nausea or vomiting 1
• Avoiding the use of opioids or butalbital for the treatment of acute episodic migraine 1
• Considering the use of CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen 1
• Counseling patients to 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
• Highlighting the importance of lifestyle modifications with patients, 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, where applicable, pursuing weight loss for those who are overweight or obese 1. Overall, the treatment of migraine headaches should be individualized and based on the specific needs and circumstances of each patient, with the goal of reducing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. In all 3 trials, the percentage of patients achieving headache response 2 and 4 hours after treatment was significantly greater among patients receiving sumatriptan tablets at all doses compared with those who received placebo For patients with migraine-associated nausea, photophobia, and/or phonophobia at baseline, there was a lower incidence of these symptoms at 2 hours (Trial 1) and at 4 hours (Trials 1,2, and 3) following administration of sumatriptan tablets compared with placebo

Treatment Options for Migraine Headaches:

• Sumatriptan tablets are effective in the acute treatment of migraine headaches.
• The medication is available in doses of 25,50, and 100 mg.
• Patients can take a second dose of sumatriptan tablets or other medication for pain relief 4 to 24 hours after the initial dose if the migraine pain has not improved or worsened 2.
• Acetaminophen can be offered to patients 2 hours after initial treatment if the migraine pain has not improved or worsened 2.

From the Research

Treatment Options for Migraine Headaches

• Acetaminophen, nonsteroidal anti-inflammatory drugs, triptans, antiemetics, ergot alkaloids, and combination analgesics have evidence supporting their effectiveness in the treatment of migraine 3
• Triptans, such as sumatriptan, are first-line treatments for moderate to severe migraines and have been shown to be effective in relieving migraine headache and associated symptoms 4, 5
• Sumatriptan is a potent and selective agonist at a vascular serotonin1 receptor subtype and is used in acute treatment of migraine and cluster headache 4
• Combination treatment using sumatriptan plus metoclopramide may be effective for patients who have failed to respond to triptans alone 6

Acute Treatment

• Sumatriptan 100mg orally has been shown to achieve relief of migraine headache in 50 to 67% of patients compared with 10 to 31% with placebo 4
• Subcutaneous sumatriptan 6mg has been shown to achieve headache relief in 70 to 80% of patients with migraine compared with 18 to 26% of placebo recipients 4
• Oral sumatriptan 100mg was also more effective than aspirin 900mg plus metoclopramide 10mg orally in a similar study 4

Preventive Therapy

• First-line medications for migraine prophylaxis include propranolol, metoprolol, topiramate, divalproex, valproate, and calcitonin gene-related peptide receptor antagonists 7
• OnabotulinumtoxinA (Botox) injection is approved for chronic migraine prophylaxis and has been shown to be effective and well tolerated 7
• Cognitive behavior therapy, acupuncture, neural stimulators, and exercise are supported by varying levels of evidence and can be used individually or in combination with pharmacotherapy 7