What are the treatment options for migraine headaches?

From the Guidelines

Migraine treatment should start with over-the-counter medications like ibuprofen (400-600mg) or naproxen (500-550mg) at the first sign of headache, and if ineffective, triptans such as sumatriptan (50-100mg orally) can be used, as recommended by the most recent study 1. For acute treatment, the goal is to relieve pain and other symptoms as quickly as possible.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen are first-line therapy, as they have the most consistent evidence for effectiveness 1.
• If NSAIDs are ineffective, triptans such as sumatriptan, rizatriptan, and zolmitriptan can provide relief within 2 hours 1.
• For severe nausea, adding an antiemetic like metoclopramide (10mg) can help, and non-oral triptans can be considered if nausea or vomiting is a significant component of the symptom complex 1. Preventive treatment is recommended for patients with frequent migraines (4+ monthly) or significant disability.
• First-line preventives include propranolol (80-240mg daily), topiramate (50-200mg daily), amitriptyline (10-150mg nightly), or valproate (500-1500mg daily) 1.
• Newer options include CGRP antagonists like erenumab (70-140mg monthly injection) or rimegepant (75mg every other day), although the evidence for these is still emerging. Non-pharmacological approaches are also important:
• Identifying and avoiding triggers (certain foods, stress, irregular sleep) can help reduce migraine frequency and severity.
• Maintaining regular sleep patterns, staying hydrated, exercising regularly, and practicing stress management techniques like meditation can also be beneficial. Neuromodulation devices and Botox injections (155-195 units every 12 weeks) may help treatment-resistant cases, although the evidence for these is still limited. The most recent study 1 provides the strongest evidence for the effectiveness of these treatments, and should be prioritized in clinical decision-making.

From the FDA Drug Label

The efficacy of rizatriptan benzoate orally disintegrating tablets in pediatric patients 6 to 17 years was evaluated in a multicenter, randomized, double-blind, placebo-controlled, parallel group clinical trial (Study 7) Patients had to have at least a 6 month history of migraine attacks (with or without aura) usually lasting 3 hours or more (when untreated). The patient population was historically non-responsive to NSAIDs and acetaminophen therapy. Patients were instructed to treat a single migraine attack with headache pain of moderate to severe intensity.

The treatment options for migraine headaches include:

• Rizatriptan benzoate orally disintegrating tablets 2
• Sumatriptan 3 These medications are used to treat migraine headaches, but the FDA drug label does not provide a comprehensive list of all available treatment options.

From the Research

Treatment Options for Migraine Headaches

• Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, antiemetics, ergot alkaloids, and combination analgesics are effective in treating migraine headaches 4
• First-line treatments for mild to moderate migraines include acetaminophen and NSAIDs, while triptans are first-line treatments for moderate to severe migraines 4
• Over-the-counter medications such as acetaminophen, ibuprofen, naproxen, and aspirin are considered first-line therapy for most migraineurs and have shown strong efficacy in treating mild-to-moderate migraine attacks 5
• Other treatment options include:
  • Dihydroergotamine and antiemetics as second- or third-line therapy for select patients or those with refractory migraine 4
  • Gepants (small-molecule calcitonin gene-related peptide receptor antagonists) and ditans (stimulators of 5-HT1F receptors) 6
  • Electrical nerve stimulation devices and magnetic stimulation devices as alternative, non-drug treatment options 6
  • Behavioral medicine techniques such as biofeedback training and mindfulness 6

Acute Care Treatment of Migraine

• Current acute treatment options for migraine attacks include over-the-counter analgesics, nonsteroidal anti-inflammatory medications, opioids, and migraine-specific medications such as triptans and ergots 6
• The administration of acute medications should follow the concept of "stratified care" 7
• For mild to moderate migraine attacks, oral NSAIDs are the first choice, with oral aspirin, combination analgesics, intravenous/intramuscular NSAIDs as alternatives 7
• For moderate to severe attacks, oral or nasal spray triptans and ergotamine/caffeine compounds are recommended and should be administered in the early stage of migraine attacks 7

Preventive Therapy for Migraine

• Preventive medication therapy reduces migraine frequency, severity, and headache-related distress, and may also improve quality of life and prevent the progression to chronic migraines 8
• First-line medications established as effective based on clinical evidence include divalproex, topiramate, metoprolol, propranolol, and timolol 8
• Complementary treatments such as petasites, feverfew, magnesium, and riboflavin are probably effective, as are nonpharmacologic therapies such as relaxation training, thermal biofeedback combined with relaxation training, electromyographic feedback, and cognitive behavior therapy 8