Best Treatment for Migraines
For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy for acute attacks, while propranolol, timolol, amitriptyline, divalproex sodium, and sodium valproate are the recommended first-line preventive agents for those requiring prophylaxis. 1
Acute Treatment Algorithm
First-Line Treatment
- NSAIDs: The most consistent evidence supports:
Note: Acetaminophen alone has limited evidence for efficacy and should only be used in patients who cannot tolerate NSAIDs 1
Second-Line Treatment
If NSAIDs fail to provide adequate relief:
- Triptans: All have documented effectiveness 1
- Sumatriptan (oral, nasal spray, or subcutaneous injection)
- Rizatriptan
- Zolmitriptan
- Naratriptan
- Eletriptan (shown to provide headache response in 54-65% of patients at 40mg dose) 2
Clinical Pearl: Triptans are most effective when taken early in an attack while pain is still mild 1. If one triptan fails, others may still provide relief.
Third-Line Treatment
For patients who fail all triptans or have contraindications:
- Lasmiditan (ditan)
- Ubrogepant or rimegepant (gepants) 1
- Oral opioid combinations (only when sedation is not a concern and risk of abuse has been addressed) 1
Special Considerations
- For patients with significant nausea/vomiting: Use non-oral routes of administration (subcutaneous, nasal spray) and add an antiemetic 1
- For rapid onset migraines: Consider subcutaneous sumatriptan 1
- For headache recurrence: May repeat triptan dose or combine with fast-acting NSAID 1
Preventive Treatment
When to Initiate Prevention
Preventive therapy should be considered when:
- Two or more attacks per month with disability lasting ≥3 days/month
- Contraindication to or failure of acute treatments
- Use of abortive medications more than twice per week
- Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura, migrainous infarction) 1, 3
First-Line Preventive Agents
Beta-blockers:
- Propranolol (80-240 mg/day)
- Timolol (20-30 mg/day) 1
Tricyclic antidepressants:
- Amitriptyline (30-150 mg/day) 1
Anticonvulsants:
- Divalproex sodium (500-1500 mg/day)
- Sodium valproate (800-1500 mg/day) 1
Second-Line Preventive Agents
- Topiramate
- Flunarizine (where available)
- Metoprolol, atenolol, nadolol (limited evidence) 1
- Candesartan 4
Nutraceuticals with Evidence
Implementation Tips
For acute treatment:
- Start with appropriate NSAID dose at first sign of migraine
- If inadequate response after 2 hours, move to triptan therapy
- Educate patients to limit acute medication use to <10 days/month to prevent medication overuse headache
For preventive treatment:
- Start with low dose and titrate slowly
- Allow 2-3 months for full therapeutic effect before judging efficacy
- Avoid interfering medications (especially overused acute medications)
- Consider tapering after 6-12 months of good control
Common Pitfalls to Avoid
- Overuse of acute medications leading to medication overuse headache (MOH)
- Inadequate dosing of preventive medications or insufficient trial duration
- Failure to address comorbidities that may exacerbate migraines (depression, anxiety, sleep disorders)
- Not considering non-oral routes when nausea/vomiting are prominent
- Relying on opioids for routine migraine management
Patient Monitoring and Education
- Have patients maintain headache diaries to track frequency, severity, duration, and response to treatments
- Educate about trigger identification and lifestyle modifications
- Set realistic expectations about treatment goals (reduction in frequency and severity, not complete elimination)
- Regular follow-up to assess treatment efficacy and adjust as needed
By following this structured approach to migraine management, both acute attacks and long-term disability can be effectively managed, improving quality of life and reducing morbidity for migraine sufferers.