What are the recommended treatments for migraines?

Recommended Treatments for Migraines

For acute migraine treatment, combination therapy with a triptan (such as sumatriptan) plus an NSAID or acetaminophen is recommended as first-line treatment due to superior efficacy compared to monotherapy. 1, 2

Acute Treatment Algorithm

First-Line Options:

• NSAIDs:

  • Ibuprofen 400-800mg
  • Naproxen sodium 500mg
  • Aspirin
  • Acetaminophen 1000mg (if NSAIDs contraindicated)

• Combination therapy (preferred approach):

  • Triptan + NSAID or acetaminophen
  • Aspirin-acetaminophen-caffeine combinations

Second-Line Options (for inadequate response to first-line):

• Triptans alone:
  • Sumatriptan 25-100mg (50mg often provides optimal balance of efficacy and side effects) 3
  • Other triptans (rizatriptan, zolmitriptan)

Third-Line Options (for inadequate response to triptans):

• CGRP antagonists (gepants):

  • Rimegepant
  • Ubrogepant
  • Zavegepant

• Ergot alkaloids:

  • Dihydroergotamine (intranasal or injectable)

Fourth-Line Option:

• Ditan:
  • Lasmiditan (for patients who don't respond to all other treatments) 1

For Patients with Severe Nausea/Vomiting:

• Non-oral triptan formulations (nasal spray, injection)
• Antiemetics (e.g., metoclopramide IV) 2

Important Considerations

Medications to Avoid:

• Opioids - not recommended for migraine treatment 1, 2
• Butalbital-containing medications - risk of dependence and medication overuse headache 2

Timing of Treatment:

• Begin treatment as soon as possible after migraine onset for better efficacy 1
• Early treatment during mild pain phase provides significantly better outcomes than treating established attacks 4

Medication Overuse Risk:

• Limit acute treatments to avoid medication overuse headache:
  • Triptans: <10 days/month
  • NSAIDs: <15 days/month 1, 2

Special Populations:

• Pregnancy/Breastfeeding: Discuss adverse effects of treatments during pregnancy and lactation 1
• Hepatic Impairment: For sumatriptan, maximum single dose should not exceed 50mg in mild to moderate hepatic impairment 3

Preventive Treatment

Consider preventive treatment if:

• Frequent episodic migraines
• Inadequate response to acute treatments 1
• Risk of progression to chronic migraine 5

Preventive Options:

1. Beta-blockers:

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

2. Anti-seizure medications:

   • Topiramate (50-200 mg/day)
   • Divalproex sodium (500-1500 mg/day)

3. CGRP antagonists:

   • Erenumab
   • Fremanezumab
   • Galcanezumab

4. Other options:

   • Amitriptyline (30-150 mg/day)
   • Angiotensin II receptor blockers (candesartan, telmisartan)
   • Oral magnesium

5. For chronic migraine:

   • OnabotulinumtoxinA injections 5

Lifestyle Modifications

• Regular sleep schedule
• Regular meal times
• Moderate to intense aerobic exercise
• Stress management techniques
• Maintaining hydration
• Weight loss if overweight/obese 1, 2

Clinical Pearls

• Approximately 90% of migraine patients can be effectively managed in primary care 2
• Sumatriptan 100mg provides better pain-free response than 50mg, but with increased adverse events 3, 4
• The NNT for sumatriptan 100mg for pain-free at 2 hours is 4.7, while for 50mg it's 6.1 4
• Consider referral to specialist if treatments fail despite optimization or diagnosis is uncertain 2