What are the treatment options for migraine headaches?

Treatment Options for Migraine Headaches

For acute migraine treatment, first-line therapy should be NSAIDs for mild to moderate attacks, and combination therapy with a triptan plus NSAID for moderate to severe attacks. 1

Acute Treatment Algorithm

First-Line Options:

• For mild to moderate migraines:

  • NSAIDs (aspirin, ibuprofen, naproxen sodium, diclofenac) 1
  • Combination of acetaminophen + aspirin + caffeine 1

• For moderate to severe migraines:

  • Combination of triptan + NSAID (most effective option) 1
  • Triptan alone if NSAIDs are contraindicated 1

Second-Line Options (if first-line fails):

• CGRP antagonists-gepants (rimegepant, ubrogepant, zavegepant) 1
• Ergot alkaloids (dihydroergotamine) - particularly intranasal formulation 1

Third-Line Options:

• Ditan lasmiditan - for patients who don't respond to or tolerate other treatments 1

For Migraines with Significant Nausea/Vomiting:

• Use non-oral routes of administration (nasal sprays, injections) 1
• Consider adding an antiemetic 1

Important Considerations

Medication Overuse Warning

• Avoid using acute medications more than 10-15 days per month to prevent medication overuse headache 1
• The threshold varies by medication: ≥15 days/month for NSAIDs; ≥10 days/month for triptans 1

Medications to Avoid

• Do not use opioids or butalbital for migraine treatment 1
• Acetaminophen alone is ineffective for migraine 1

Route of Administration

• For severe nausea/vomiting, consider:
  • Subcutaneous sumatriptan (fastest onset of action) 1, 2
  • Intranasal triptans or DHE 1

Non-Pharmacological Approaches

Lifestyle Modifications:

• Stay well hydrated 1
• Maintain regular meal patterns 1
• Ensure sufficient and consistent sleep 1, 3
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1
• Manage stress with relaxation techniques or mindfulness practices 1, 3
• Pursue weight loss if overweight or obese 1

Dietary Considerations:

• Identify and avoid personal food triggers through food diaries 4
• Common triggers may include:
  • Alcohol
  • Caffeine
  • Foods containing tyramine or nitrates
  • Aspartame
  • Monosodium glutamate 1, 4

Preventive Treatment

Consider preventive therapy when:

• Patient experiences ≥2 migraine attacks per month with significant disability 1
• Acute medications are overused, contraindicated, or ineffective 1, 5
• Special circumstances exist (e.g., hemiplegic migraine) 5

First-Line Preventive Options:

• Beta-blockers (propranolol, timolol) 1, 5
• Antidepressants (amitriptyline) 1, 5
• Anticonvulsants (divalproex sodium, topiramate) 1, 5

Supplements with Evidence for Prevention:

• Magnesium
• Riboflavin (vitamin B2)
• Coenzyme Q10 3, 4

Common Pitfalls to Avoid

1. Delayed treatment - Counsel patients to begin treatment as soon as possible after migraine onset 1
2. Inadequate dosing - Ensure patients use appropriate medication doses before concluding a treatment is ineffective 1
3. Overreliance on single agents - Combination therapy (triptan + NSAID) is more effective than monotherapy for moderate-severe attacks 1
4. Medication overuse - Limit acute treatments to prevent rebound headaches 1
5. Ignoring non-pharmacological approaches - Lifestyle modifications should complement medication therapy 1, 3

By following this structured approach to migraine management, most patients can achieve significant improvement in their migraine frequency, severity, and associated disability.