What are the recommended medications for treating migraines?

Recommended Medications for Treating Migraines

NSAIDs (ibuprofen, naproxen, aspirin) are recommended as first-line treatment for acute migraine attacks, with triptans (sumatriptan, rizatriptan, zolmitriptan) recommended as second-line therapy, while beta-blockers, anti-seizure medications, and CGRP antagonists are recommended for migraine prevention. 1

Acute Treatment Options

First-Line Treatments

• NSAIDs:

  • Ibuprofen (400-800mg)
  • Naproxen sodium (500mg)
  • Aspirin
  • Aspirin-acetaminophen-caffeine combinations 1

• Acetaminophen:

  • 1000mg is a viable option if NSAIDs are contraindicated
  • Less efficacious than NSAIDs 1

Second-Line Treatments

• Triptans:

  • Sumatriptan (25-100mg)
  • Rizatriptan
  • Zolmitriptan
  • 52-62% of patients achieve headache response within 2 hours 1
  • Sumatriptan 50mg and 100mg doses provide better efficacy than 25mg, with 50mg offering the best efficacy-to-tolerability ratio 2
  • Contraindicated in: uncontrolled hypertension, basilar or hemiplegic migraine, patients at risk for heart disease 1

• CGRP Antagonists:

  • Rimegepant
  • Ubrogepant 1

For Significant Nausea

• Antiemetics:
  • Metoclopramide (IV) 1

Combination Therapy

• Triptan plus NSAID or acetaminophen provides superior relief compared to monotherapy 1

Preventive Treatment Options

First-Line Preventive Medications

• Beta-blockers:

  • Propranolol (80-240 mg/day)
  • Metoprolol
  • Timolol (20-30 mg/day) 1

• Anti-seizure medications:

  • Topiramate (50-200 mg/day)
  • Divalproex sodium (500-1500 mg/day)
  • Sodium valproate (800-1500 mg/day) 1

• CGRP antagonists:

  • Erenumab
  • Fremanezumab
  • Galcanezumab 1

Additional Preventive Options

• Angiotensin II receptor blockers:

  • Candesartan
  • Telmisartan 1

• Tricyclic antidepressants:

  • Amitriptyline (30-150 mg/day) 1

• Supplements:

  • Oral magnesium 1

Medications to Avoid

• Butalbital-containing medications: Risk of dependence and medication overuse headache 1

• Opioids: Risk of dependency and questionable efficacy 1

• Ergot alkaloids: Considerable adverse effects including risk of dependency 1, 3

  • Ergotamine can cause intense arterial vasoconstriction and peripheral vascular ischemia 3

• IV ketamine: Specifically recommended against by 2024 VA/DoD guidelines 1

Important Considerations

Medication Overuse Prevention

• Limit acute treatments to 2 or fewer days per week
• Maximum of <10 days/month for triptans
• Maximum of <15 days/month for NSAIDs 1

Treatment Timing

• Treating early during mild pain phase provides better outcomes than treating established attacks with moderate/severe pain 4

Intravenous Therapy

• Reserve IV therapies for situations where oral medications cannot be used or have failed
• IV magnesium should not replace standard treatments with stronger evidence 1

Status Migrainosus (prolonged attack >72 hours)

• Consider IV hydration, dexamethasone, and naratriptan 1

Monitoring

• Use a headache diary to track frequency, severity, and medication use 1

Referral Considerations

• Refer to neurologist or headache specialist if:
  • All treatments fail despite optimization
  • Diagnosis is uncertain
  • Headaches are complicated by comorbidities
  • Patient uses acute medications more than twice weekly 1

Approximately 90% of migraine patients can be effectively managed in primary care with proper medication selection and dosing 1.