What is the best medication for migraines?

Best Medications for Migraines

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are the recommended first-line therapy, with triptans being the most effective second-line option when NSAIDs fail to provide relief. 1

Treatment Algorithm for Acute Migraine

First-Line Treatment: NSAIDs

• Specific recommended NSAIDs:
  • Aspirin (650-1000 mg)
  • Ibuprofen (400-800 mg)
  • Naproxen sodium (275-550 mg)
  • Combination of acetaminophen + aspirin + caffeine 1

Note: Acetaminophen alone is not recommended for migraine treatment as evidence shows it is ineffective. 1

Second-Line Treatment: Triptans

When NSAIDs fail to provide adequate relief, triptans should be used:

• Recommended triptans with good evidence:
  • Sumatriptan (oral 25-100 mg, subcutaneous 6 mg)
  • Rizatriptan (oral)
  • Zolmitriptan (oral)
  • Naratriptan (oral) 1

Sumatriptan 50 mg and 100 mg doses are more effective than the 25 mg dose, with the 100 mg dose showing significantly better pain relief at 2 hours (NNT 4.7 vs 6.1 for 50 mg). 2

Special Considerations:

• For migraines with significant nausea/vomiting: Use non-oral routes of administration (subcutaneous sumatriptan, nasal DHE) and add an antiemetic 1
• For severe migraines unresponsive to other treatments: Consider opioids only when sedation side effects are not a concern and risk of abuse has been addressed 1

Preventive Treatment

Preventive therapy should be considered when:

1. Two or more attacks per month producing disability lasting 3+ days per month
2. Contraindication to or failure of acute treatments
3. Use of abortive medication more than twice per week
4. Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura, migrainous infarction) 1

First-line preventive medications:

• Propranolol (80-240 mg/day)
• Timolol (20-30 mg/day)
• Amitriptyline (30-150 mg/day)
• Divalproex sodium (500-1500 mg/day)
• Sodium valproate (800-1500 mg/day) 1

Important Considerations and Pitfalls

• Medication overuse headache: Limit acute treatments to no more than twice weekly to prevent rebound headaches 1
• Triptan contraindications: Do not use in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or cardiovascular disease risk 1, 3
• Timing of treatment: Triptans are most effective when taken early in an attack while pain is still mild 1
• Recurrence: Headache may recur in 21-57% of patients after sumatriptan treatment, but most respond to a second dose 4
• Side effects: Most common adverse events with oral sumatriptan include nausea, vomiting, malaise, and fatigue; subcutaneous administration often causes injection site reactions 4, 5

Treatment Selection Based on Migraine Severity

• Mild to moderate attacks: NSAIDs (oral)
• Moderate to severe attacks or those responding poorly to NSAIDs: Triptans or combination therapy
• Severe attacks with nausea/vomiting: Non-oral routes (subcutaneous sumatriptan, nasal DHE) plus antiemetic 1

By following this evidence-based approach to migraine treatment, focusing on both acute management and prevention when appropriate, patients can experience significant reductions in migraine-related disability and improved quality of life.