What are the treatment options for migraine headaches?

Treatment Options for Migraine Headaches

For migraine headaches, first-line treatment should be NSAIDs or acetaminophen for mild to moderate attacks, while triptans are recommended for moderate to severe migraines or when NSAIDs are ineffective. 1

Acute Treatment Algorithm

Mild to Moderate Migraine

1. First-line options:

   • NSAIDs:
     • Ibuprofen 400-800mg
     • Naproxen 500-550mg
   • Acetaminophen 1000mg

2. If inadequate response:

   • Add a triptan to NSAID/acetaminophen
   • Consider non-oral routes if severe nausea/vomiting present

Moderate to Severe Migraine

1. First-line options:

   • Triptans (sumatriptan, rizatriptan, zolmitriptan, almotriptan, eletriptan, frovatriptan, naratriptan)
   • Consider combination with NSAID for enhanced efficacy

2. Second-line options:

   • Dihydroergotamine (DHE) (contraindicated in pregnancy)
   • Butorphanol nasal spray

Administration Considerations

• Start treatment as early as possible after onset for improved efficacy
• If one medication in a class fails, try another in the same class before moving to next line
• For severe nausea/vomiting, use non-oral routes of administration
• Avoid opioids and butalbital due to risk of medication overuse headache

Preventive Treatment

When to Consider Prevention

Preventive treatment should be initiated when:

• ≥4 migraine days per month
• Significant disability despite appropriate acute treatment
• Frequent or disabling headaches
• Medication overuse

Preventive Medication Options

1. First-line preventives:

   • 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)
     • Sodium valproate (800-1500 mg/day)

2. For chronic migraine (≥15 headache days/month):

   • OnabotulinumtoxinA (Botox) 2
     • Important safety note: Monitor for difficulty swallowing, speaking, or breathing after injection

Special Considerations for Preventive Medications

• Valproate products: Be aware of potential side effects including hair loss, skin reactions, liver function abnormalities, and pancreatic issues 3
• OnabotulinumtoxinA: Contraindicated in patients with hypersensitivity to botulinum toxin products; use with caution in patients with neuromuscular disorders 2
• Assess response to preventive treatment after 2-3 months
• Limit acute medications to ≤10 days per month to prevent medication overuse headache

Non-Pharmacological Approaches

Lifestyle Modifications

• Maintain regular sleep patterns and meal times
• Ensure adequate hydration
• Implement regular exercise
• Limit caffeine intake

Behavioral Interventions

• Cognitive-behavioral therapy (CBT)
• Biofeedback
• Relaxation training
• Mindfulness meditation
• Progressive muscle relaxation

Complementary Therapies

• Supplements with fair evidence for modest efficacy:
  • Magnesium
  • Riboflavin (Vitamin B2)
  • Feverfew
• Consider neuromodulatory devices and acupuncture for patients who prefer to avoid pharmacological options

When to Refer to a Specialist

• Headaches remain refractory to multiple treatment options
• Atypical headache features
• Abnormal findings on neurological examination
• Need for neuroimaging (CT or MRI) due to red flags

Treatment Efficacy and Expectations

Research shows that NSAIDs like ibuprofen provide pain relief in about half of migraine sufferers, with complete relief occurring in only a minority of patients 4. The higher dose of 400mg ibuprofen is more effective than 200mg, with soluble formulations providing more rapid relief 4. Diclofenac potassium 50mg has also shown effectiveness for acute migraine, though only a minority of patients experience pain-free responses 5.

While many patients rely on over-the-counter medications due to their accessibility and lower cost 6, it's important to recognize that migraine is a neurobiological disorder that may require more specific treatments for optimal management, especially in cases of moderate to severe or disabling attacks 7.