What are the recommended medications for treating migraines?

Recommended Medications for Migraine Treatment

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy for acute attacks, while triptans should be used when NSAIDs fail or for moderate to severe migraines. 1, 2

Acute Treatment Algorithm

First-Line Therapy (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
  • Acetaminophen-aspirin-caffeine combination

Note: Acetaminophen alone is ineffective and should not be used as monotherapy 2, 1

Second-Line Therapy (Moderate to Severe Attacks or NSAID Failure)

• Triptans:
  • Sumatriptan 50-100 mg orally
  • Rizatriptan 5-10 mg orally
  • Zolmitriptan 2.5-5 mg orally
  • Naratriptan 1-2.5 mg orally

Clinical evidence shows that sumatriptan 100 mg provides better pain-free response than 50 mg, with NNT of 4.7 versus 6.1 for pain-free at two hours 3

Special Considerations for Nausea/Vomiting

• Use non-oral routes when nausea/vomiting is prominent:
  • Sumatriptan subcutaneous injection 6 mg
  • Intranasal triptans
  • Dihydroergotamine (DHE) nasal spray
• Add antiemetics to treat nausea even in patients who are not vomiting 2

Contraindications and Precautions

• Triptans are contraindicated in:

  • Uncontrolled hypertension
  • Coronary artery disease
  • Basilar or hemiplegic migraine
  • Within 24 hours of ergotamine use 1, 4

• Opioids should be avoided except when other medications cannot be used, risk of abuse has been addressed, and sedation is not a concern 2, 1

Preventive Therapy

Indications for Preventive Therapy

Evaluate for preventive therapy if patient has:

• Two or more attacks per month with disability lasting ≥3 days/month
• Failure of or contraindication to acute treatments
• Use of abortive medication more than twice per week
• Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 2

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 2, 1

Common Pitfalls and How to Avoid Them

1. Medication Overuse Headache:

   • Limit acute therapy to no more than twice per week
   • Consider preventive therapy if acute medications are needed frequently 2, 1

2. Delayed Treatment:

   • Triptans are most effective when taken early while pain is still mild 3
   • Using the "stratified-care" approach (assigning treatment based on migraine severity) is superior to the "step-care" approach 1

3. Inadequate Treatment of Associated Symptoms:

   • Always address nausea, even in patients who are not vomiting
   • Consider non-oral routes when nausea/vomiting is prominent 2, 1

4. Recurrence:

   • Approximately 40% of patients experience headache recurrence within 24 hours after initial response to triptans
   • A second dose of the same medication is usually effective for recurrence 5, 4

5. Ignoring Patient Preferences:

   • Patient preference studies show varying preferences for triptan dosing
   • Some patients prefer higher doses (100 mg) for better efficacy despite slightly more side effects 6

By following this evidence-based approach to migraine management, clinicians can significantly reduce patient morbidity and improve quality of life through effective control of both acute attacks and prevention of future episodes.