What is the first line treatment for migraine headaches?

First-Line Treatment for Migraine Headaches

NSAIDs (such as ibuprofen 400-800 mg or naproxen 500-550 mg) are the first-line treatment for migraine headaches, with the addition of an antiemetic if nausea is present. 1

Acute Treatment Algorithm

First-Line Options:

• NSAIDs
  • Ibuprofen 400-800 mg
  • Naproxen sodium 500-550 mg (provides longer duration of action)
  • Can be combined with antiemetic (metoclopramide 10 mg) if nausea is present

If inadequate response after 2 hours or for moderate to severe migraines:

• Add or switch to a triptan 2, 1
  • Sumatriptan 25-100 mg (50 mg is often optimal as 100 mg may not provide additional benefit but may increase side effects) 3
  • Take early in the attack for best results

For patients with significant nausea/vomiting:

• Add metoclopramide 10 mg (improves gastric motility and treats nausea)
• Consider non-oral routes of administration for medications

Treatment Considerations

Efficacy Data:

• Sumatriptan shows headache response rates of 50-62% at 2 hours and 65-79% at 4 hours compared to placebo (17-27% at 2 hours and 19-38% at 4 hours) 3
• NSAIDs have demonstrated effectiveness for mild to moderate migraines 1, 4
• Acetaminophen 1000 mg can be effective (57.8% response rate vs 38.7% for placebo) but is generally less effective than NSAIDs 5

Special Populations:

• Older adults: Exercise caution with triptans due to potential cardiovascular risks
• Patients with cardiovascular risk factors: Monitor blood pressure if using triptans
• Women of childbearing potential: Avoid valproate due to teratogenicity 2, 1

Prevention of Medication Overuse Headache

• Limit acute medication use to prevent medication overuse headaches
• Consider preventive therapy if migraines occur ≥2 days per month despite optimized acute treatment 2

First-Line Preventive Options (if needed):

• Beta blockers (atenolol, bisoprolol, metoprolol, propranolol)
• Topiramate
• Candesartan 2

Common Pitfalls to Avoid

1. Delayed treatment: Taking medication too late in the attack reduces effectiveness
2. Inadequate dosing: Underdosing NSAIDs or triptans leads to treatment failure
3. Overuse of medication: Can lead to medication overuse headaches
4. Ignoring accompanying symptoms: Nausea requires specific management with antiemetics
5. Missing contraindications: Triptans should be used cautiously in patients with cardiovascular disease

By following this stepped approach to migraine treatment, starting with NSAIDs and escalating to triptans when needed, most patients can achieve effective relief from migraine headaches while minimizing side effects and preventing medication overuse.