What are the treatment options for migraines?

Migraine Treatment Options

NSAIDs are the first-line treatment for most migraine sufferers, followed by triptans for moderate to severe attacks or when NSAIDs fail. 1

Acute Treatment Algorithm

First-Line Treatment

• For mild to moderate attacks:

  • NSAIDs with strongest evidence 1:
    • Aspirin (650-1000 mg every 4-6 hours, max 4g/day)
    • Ibuprofen (400-800 mg every 6 hours, max 2.4g/day)
    • Naproxen sodium (275-550 mg every 2-6 hours, max 1.5g/day)
    • Combination of acetaminophen + aspirin + caffeine

  Note: Acetaminophen alone is NOT recommended for migraine 1

Second-Line Treatment

• For moderate to severe attacks OR when NSAIDs fail:

  • Triptans 1:
    • Sumatriptan (oral: 25-100 mg; subcutaneous: 6 mg)
    • Rizatriptan (oral)
    • Zolmitriptan (oral)
    • Naratriptan (oral)

  Clinical pearl: Triptans are most effective when taken early in an attack while pain is still mild 1

Third-Line Treatment

• When triptans fail or are contraindicated:
  • Dihydroergotamine (DHE) nasal spray 1
  • Newer agents (limited availability):
    • Ditans (lasmiditan)
    • Gepants (ubrogepant, rimegepant) 1
  • Rescue medications:
    • Opioids (use cautiously due to risk of dependence) 1
    • Butorphanol nasal spray 1

Special Considerations

• For attacks with significant nausea/vomiting:
  • Use non-oral routes of administration 1
  • Add antiemetics like metoclopramide (10 mg) or prochlorperazine 1
  • Consider subcutaneous sumatriptan (6 mg) for rapid relief 1, 2

Preventive Treatment

Consider preventive therapy when 1:

1. Two or more attacks per month with disability lasting ≥3 days
2. Acute treatments fail or are contraindicated
3. Using acute medications more than twice weekly
4. Presence of uncommon migraine conditions (hemiplegic, prolonged aura, migrainous infarction)

First-Line Preventive Medications 1

• 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)

Important Clinical Considerations

Medication Overuse Risk

• Limit acute treatments to no more than twice weekly to prevent medication-overuse headache 1
• Medication overuse can lead to chronic daily headaches and reduced effectiveness of treatments 2

Triptan Contraindications

• Uncontrolled hypertension
• Coronary artery disease
• Basilar or hemiplegic migraine
• Recent use of MAO inhibitors 2

Treatment Efficacy

• Sumatriptan 50 mg and 100 mg provide better pain relief than 25 mg, with NNTs of 3.2 and 3.4 respectively for headache relief at 2 hours 3, 4
• Early treatment during mild pain phase significantly improves outcomes 4
• Subcutaneous sumatriptan provides the fastest relief but with more adverse effects 5

Adverse Effects

• Most common triptan side effects: nausea, dizziness, chest/throat tightness, fatigue 2, 4
• NSAIDs: GI upset, dizziness, risk of GI bleeding with prolonged use 1

Patient Education

• Track migraine attacks with a diary to identify triggers and evaluate treatment response 1
• Take medications early in the attack for optimal effectiveness 1
• Avoid overuse of acute medications to prevent rebound headaches 1
• Consider lifestyle modifications to address potential triggers 1

By following this stepped care approach and individualizing treatment based on attack severity, associated symptoms, and patient response, most migraine sufferers can achieve significant relief and improved quality of life.