What are the treatment options for migraine headaches?

Treatment Options for Migraine Headaches

The first-line treatment for moderate to severe migraine headaches should begin with NSAIDs or acetaminophen, followed by adding a triptan if adequate relief is not achieved. 1, 2

Stepwise Treatment Approach

First-Line Treatments

• For mild to moderate migraine:
  • NSAIDs (aspirin, ibuprofen, naproxen, diclofenac) at appropriate dosages 1, 2
    • Ibuprofen 400-800mg
    • Naproxen 500-550mg
  • Acetaminophen 1000mg 1, 3
  • Combination of NSAID and acetaminophen 1

Second-Line Treatments

• For moderate to severe migraine or inadequate response to first-line:
  • Add a triptan to an NSAID or acetaminophen 1
    • Options include: sumatriptan, rizatriptan, zolmitriptan, almotriptan, eletriptan, frovatriptan, or naratriptan 1, 4, 5
  • Consider non-oral triptans with antiemetics if severe nausea/vomiting is present 1, 2

Third-Line Treatments

• For patients who don't respond to or cannot tolerate combination therapy:
  • CGRP antagonists (rimegepant, ubrogepant, zavegepant) 1
  • Dihydroergotamine (contraindicated in pregnancy) 1, 2
  • Lasmiditan (ditan) as last resort 1

Important Clinical Considerations

Medication Selection

1. Route of administration:

   • Oral is standard for most patients
   • Non-oral routes (nasal, injectable) for those with severe nausea/vomiting 1, 2

2. Timing of medication:

   • Begin treatment as early as possible after onset of migraine 1
   • Early intervention improves efficacy

3. Medication switching:

   • If one medication in a class fails, try another in the same class before moving to next line 1
   • Example: If one triptan is ineffective, try another before moving to CGRP antagonists

Cautions and Contraindications

• Avoid opioids and butalbital for migraine treatment 1
• Medication overuse headache risk:
  • NSAIDs: limit to <15 days/month
  • Triptans: limit to <10 days/month 1, 2
• Triptan contraindications:
  • Ischemic or vasospastic coronary artery disease
  • History of stroke or TIA
  • Uncontrolled hypertension 4, 5
• Risk of serotonin syndrome with triptans, especially when combined with SSRIs, SNRIs, TCAs, or MAOIs 4

Non-Pharmacological Approaches

• Lifestyle modifications:

  • Regular sleep patterns
  • Regular meals and hydration
  • Regular physical activity (moderate to intense aerobic exercise)
  • Stress management techniques 1, 2

• Behavioral interventions:

  • Cognitive-behavioral therapy
  • Biofeedback
  • Relaxation training
  • Mindfulness practices 2

Prevention Considerations

• Consider preventive treatment when:

  • Migraine occurs frequently (≥4 days/month)
  • Treatment doesn't provide adequate response
  • Significant disability despite appropriate acute treatment 1, 2

• Preventive medication options:

  • Beta-blockers (propranolol 80-240 mg/day, timolol 20-30 mg/day)
  • Tricyclic antidepressants (amitriptyline 30-150 mg/day)
  • Anticonvulsants (divalproex sodium 500-1500 mg/day) 2

Common Pitfalls to Avoid

1. Inadequate dosing: Ensure appropriate doses of NSAIDs or acetaminophen before concluding they are ineffective 1

2. Delayed treatment: Starting treatment late in the migraine attack reduces effectiveness 1

3. Medication overuse: Using acute medications too frequently can lead to medication overuse headache 1, 2

4. Ignoring cardiovascular risk: Triptans should be used cautiously in patients with cardiovascular risk factors 4, 5

5. Failure to address comorbidities: Nausea, vomiting, and sensory sensitivities should be specifically targeted 2