What are the treatment options for migraines?

Migraine Treatment Options

For acute migraine treatment, a stepped care approach is recommended, starting with NSAIDs for mild to moderate attacks, and progressing to triptans (alone or in combination with NSAIDs) for moderate to severe attacks or when NSAIDs fail to provide adequate relief. 1

Acute Treatment Algorithm

First-Line Treatment (Mild to Moderate Attacks)

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

Clinical Pearl: Acetaminophen alone is not recommended for migraine but can be effective when combined with aspirin and caffeine 1

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

• Triptans (most effective when taken early in an attack while pain is still mild):

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

• Combination therapy:

  • Triptan + NSAID (superior efficacy compared to monotherapy)
  • Aspirin + acetaminophen + caffeine 1

Important: Counsel patients to begin treatment as soon as possible after migraine onset, using combination therapy to improve efficacy 1

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

• CGRP antagonists (gepants):

  • Rimegepant
  • Ubrogepant
  • Zavegepant 1

• Ditans:

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

• Ergot derivatives:

  • Dihydroergotamine (DHE) 1

For Migraine with Nausea/Vomiting

• Use non-oral routes of administration:

  • Subcutaneous sumatriptan
  • Nasal triptans
  • Rectal NSAIDs 1

• Antiemetics (also provide synergistic analgesia):

  • Metoclopramide (10mg)
  • Prochlorperazine 1

Special Considerations

Medication Overuse Headache

• Warn patients about medication overuse headache risk:
  • NSAIDs: ≥15 days/month
  • Triptans: ≥10 days/month 1

Treatments to Avoid

• Do not use opioids or butalbital-containing medications for migraine treatment as they can lead to dependency, rebound headaches, and loss of efficacy 1

Efficacy Considerations

• Sumatriptan 100mg shows higher efficacy than 50mg for pain-free and headache relief at 2 hours 2
• Treating early during mild pain phase gives significantly better outcomes than treating established attacks 2
• Diclofenac potassium may provide faster onset of pain relief (from 60 minutes) compared to oral sumatriptan (from 90 minutes) 3

Preventive Treatment

Consider preventive therapy when:

• Two or more attacks per month causing ≥3 days of disability
• Contraindication to or failure of acute treatments
• Use of acute medications more than twice per week
• Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 1

Non-Pharmacologic Approaches

Evidence supports:

• Relaxation training
• Thermal biofeedback combined with relaxation training
• Cognitive-behavioral therapy
• Regular physical activity (moderate to intense aerobic exercise)
• Stress management with relaxation techniques
• Maintaining regular sleep and meal schedules
• Proper hydration 1

Safety Warnings

• Triptans are contraindicated in patients with coronary artery disease, uncontrolled hypertension, or history of stroke/TIA 4
• Monitor for serotonin syndrome when combining triptans with SSRIs, SNRIs, or MAOIs 4
• CGRP antagonists and lasmiditan are significantly more expensive than other treatment options 1