What are the treatment options for migraines?

Migraine Treatment Options

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy, followed by triptans for moderate to severe attacks or when NSAIDs fail. 1

Stepped Care Approach to Migraine Treatment

First-Line Treatment (Mild to Moderate Migraines)

• NSAIDs with proven efficacy:
  • Aspirin (650-1000 mg every 4-6 hours)
  • Ibuprofen (400-800 mg every 6 hours)
  • Naproxen sodium (275-550 mg every 2-6 hours)
  • Diclofenac potassium 1
  • Combination of acetaminophen + aspirin + caffeine 1

Important note: Acetaminophen alone is not recommended for migraine as evidence shows it's ineffective 1

Second-Line Treatment (Moderate to Severe Migraines or NSAID Failures)

• Triptans (5-HT1B/1D agonists):
  • Sumatriptan (oral, subcutaneous, intranasal)
  • Rizatriptan (oral)
  • Zolmitriptan (oral)
  • Naratriptan (oral) 1

Clinical pearl: Triptans are most effective when taken early in an attack while pain is still mild 1. Subcutaneous sumatriptan has the fastest onset of action and is useful for rapidly peaking headaches 1.

Dosing note for sumatriptan: Studies show 50mg and 100mg doses are more effective than 25mg, with the 50mg dose offering the best efficacy-to-tolerability ratio 2. FDA data shows headache response rates of 50-62% at 2 hours and 65-79% at 4 hours with sumatriptan tablets 3.

Third-Line Treatment (When Triptans Fail or Are Contraindicated)

• Dihydroergotamine (DHE) - particularly intranasal formulation
• Ditans (lasmiditan) or gepants (ubrogepant, rimegepant) where available 1
• Isometheptene combinations 1
• Opioids (only when other options fail and risk of abuse is addressed) 1

For Migraines with Significant Nausea/Vomiting

• Use non-oral routes of administration:
  • Subcutaneous sumatriptan
  • Intranasal triptans or DHE
  • Rectal formulations where available 1
• Add antiemetics:
  • Metoclopramide (10 mg)
  • Prochlorperazine (25 mg) 1

Preventive Treatment Indications

Consider preventive therapy when:

1. Two or more migraine attacks per month with 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 Cautions and Contraindications

• Triptans: Contraindicated in patients with:

  • Coronary artery disease or Prinzmetal's angina
  • History of stroke or TIA
  • Uncontrolled hypertension
  • Hemiplegic or basilar migraine 3

• Medication overuse headache risk: Limit acute treatments to no more than twice weekly to prevent medication overuse headache 1

• Serotonin syndrome: Use caution when combining triptans with SSRIs, SNRIs, TCAs, or MAOIs 3

Monitoring Treatment Effectiveness

Track the following parameters to evaluate treatment efficacy:

• Attack frequency, severity, and duration
• Resulting disability
• Response to treatment type
• Adverse medication effects 1

This stepped approach to migraine treatment, starting with NSAIDs and progressing to triptans and other options as needed, provides a clear framework for managing migraine attacks while minimizing risks and optimizing outcomes for patients.