What are the treatment options for migraine?

Treatment of Migraine

For effective migraine management, use a stepped care approach starting with NSAIDs for mild to moderate attacks, progressing to combination therapy with triptans for inadequate response, and reserving newer agents like gepants and ditans for treatment failures. 1

Acute Treatment Algorithm

First-Line Treatment (Mild to Moderate Attacks)

• NSAIDs:

  • Ibuprofen (400-800 mg every 6 hours)
  • Naproxen sodium (275-550 mg every 2-6 hours)
  • Aspirin (650-1000 mg every 4-6 hours)
  • Diclofenac potassium 1

• Combination analgesics:

  • Aspirin + acetaminophen + caffeine 1

Note: Acetaminophen alone is not recommended for migraine treatment 1

Second-Line Treatment (Moderate to Severe Attacks or Inadequate Response to NSAIDs)

• Triptans:

  • Sumatriptan (25-100 mg oral; 50 mg often sufficient) 2
  • Rizatriptan, zolmitriptan, almotriptan, eletriptan, frovatriptan, naratriptan 1

• Combination therapy:

  • Triptan + NSAID (provides better efficacy than either alone) 1
  • Triptan + acetaminophen (when NSAIDs are contraindicated) 1

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

Third-Line Treatment (Treatment Failures)

• CGRP antagonists (gepants):

  • Rimegepant, ubrogepant, zavegepant 1

• Ditans:

  • Lasmiditan (for patients who don't respond to or can't take other treatments) 1

• Ergot alkaloids:

  • Dihydroergotamine (DHE) nasal spray or injectable 1

For Attacks with Significant Nausea/Vomiting

• Use non-oral routes of administration:
  • Sumatriptan subcutaneous injection 2
  • Zolmitriptan or sumatriptan nasal spray
  • Add antiemetics (metoclopramide, prochlorperazine) 1

Important Clinical Considerations

Medication Administration Timing

• Administer medications as early as possible during an attack 1
• For triptans, taking medication when pain is still mild increases effectiveness 1

Medication Overuse Risk

• Monitor for medication overuse headache (MOH):
  • Occurs with use of triptans ≥10 days/month
  • Occurs with use of NSAIDs ≥15 days/month 1
• Limit opioids and butalbital-containing medications as they increase risk of MOH and dependency 1

Contraindications and Cautions

• Triptans:

  • Contraindicated in coronary artery disease, Prinzmetal's angina, stroke/TIA history, uncontrolled hypertension 2
  • Use with caution with SSRIs/SNRIs (risk of serotonin syndrome) 2

• NSAIDs:

  • Avoid in patients with GI bleeding risk, renal impairment, or NSAID-induced asthma 1

Preventive Treatment Considerations

• Consider preventive therapy when:
  • ≥2 attacks per month with disability lasting ≥3 days
  • Acute treatments fail or are contraindicated
  • Medication use exceeds twice weekly 1
  • Patient has uncommon migraine conditions (hemiplegic migraine, prolonged aura) 1

Lifestyle Modifications

• Maintain regular sleep patterns
• Stay well hydrated
• Eat regular meals
• Engage in regular physical activity
• Manage stress through relaxation techniques 1
• Identify and avoid personal trigger factors when possible 1

Treatment Goals

• Rapid and consistent relief of attacks
• Restore functional ability
• Minimize use of rescue medications
• Enable effective self-care
• Minimize adverse effects 1

Remember that early treatment of migraine attacks is crucial for optimal outcomes. While NSAIDs are effective for mild to moderate attacks, triptans remain the mainstay for moderate to severe attacks, with newer agents like gepants and ditans providing alternatives for those who fail standard therapies or have contraindications to triptans 3.