What are the treatment options for migraines?

Migraine Treatment Options

For acute episodic migraine treatment, start with NSAIDs or acetaminophen, and if inadequate relief occurs, add a triptan (combination therapy of triptan plus NSAID or acetaminophen provides superior relief compared to monotherapy). 1

First-Line Treatment Options

For Mild to Moderate Migraines:

• NSAIDs (first choice):

  • Ibuprofen 400-800mg
  • Naproxen 500mg
  • Aspirin 900mg
  • Diclofenac potassium 1

• Acetaminophen:

  • Less effective as monotherapy but useful when NSAIDs are contraindicated 1, 2
  • More effective when combined with aspirin and caffeine 1

For Moderate to Severe Migraines:

• Triptans (when NSAIDs provide inadequate relief):

  • Sumatriptan 25mg, 50mg, or 100mg
  • Rizatriptan
  • Zolmitriptan
  • Naratriptan
  • Almotriptan
  • Eletriptan
  • Frovatriptan 1, 3

• Combination therapy (most effective approach):

  • Triptan + NSAID (e.g., sumatriptan + naproxen)
  • Triptan + acetaminophen (when NSAIDs contraindicated) 1

Second-Line and Alternative Options

For Patients with Inadequate Response to First-Line Treatments:

• CGRP antagonists (gepants):

  • Rimegepant
  • Ubrogepant
  • Zavegepant 1, 2

• Ergot alkaloids:

  • Dihydroergotamine (DHE) 1

• Ditan:

  • Lasmiditan (last resort when other options fail) 1, 2

For Migraine with Significant Nausea/Vomiting:

• Non-oral routes of administration:
  • Sumatriptan subcutaneous injection (6mg) - fastest onset of action 2, 3
  • Sumatriptan intranasal spray
  • DHE nasal spray
  • Antiemetics (metoclopramide, prochlorperazine) 1, 2

Treatment Algorithm

1. Assess migraine severity:

   • Mild to moderate: Start with NSAID or acetaminophen
   • Moderate to severe: Consider triptan or combination therapy immediately

2. If initial treatment fails:

   • Add a triptan to NSAID/acetaminophen
   • Try different triptan if first one ineffective
   • Consider non-oral route if nausea/vomiting present

3. For refractory cases:

   • Try CGRP antagonists or DHE
   • Consider lasmiditan as last resort
   • Evaluate for preventive therapy if attacks are frequent

Important Clinical Considerations

• Timing matters: Treat early in the attack for better efficacy 1, 4
• Avoid overuse: Medication overuse headache can occur with frequent use (≥15 days/month for NSAIDs; ≥10 days/month for triptans) 1
• Never use opioids or butalbital for migraine treatment due to dependency risk, rebound headaches, and loss of efficacy 1, 2
• Consider preventive therapy if migraine occurs frequently or treatment doesn't provide adequate response 1

Evidence Quality and Efficacy

• Sumatriptan 100mg shows superior efficacy with NNT of 4.7 for pain-free at 2 hours compared to placebo 4
• Combination therapy of triptan + NSAID/acetaminophen shows greater net benefit than monotherapy 1
• Early treatment during mild pain phase gives significantly better outcomes than treating established attacks 4
• Subcutaneous sumatriptan has faster onset (1 hour) with higher response rates (70-84%) compared to oral formulation (50-67% at 2 hours) 5

Common Pitfalls to Avoid

• Not addressing nausea as a component of migraine
• Overusing acute medications leading to medication overuse headache
• Using opioids or butalbital-containing medications
• Not considering non-oral routes when needed for patients with significant nausea/vomiting
• Failing to start treatment early in the attack

By following this evidence-based approach to migraine treatment, focusing on NSAIDs/acetaminophen for mild attacks and adding triptans for moderate-severe attacks, patients can achieve better control of their migraine symptoms and improved quality of life.