What is the best nonsteroidal anti-inflammatory drug (NSAID) for migraine treatment?

Best NSAIDs for Migraine Treatment

Ibuprofen (400-800mg) and naproxen (500-550mg) are the most effective NSAIDs for acute migraine treatment, with ibuprofen showing superior efficacy as a first-line option. 1

First-Line NSAID Options

• Ibuprofen (400-800mg)

  • Provides significant pain relief starting at 60 minutes after dosing 2
  • Both 200mg and 400mg doses effectively reduce headache intensity and provide pain-free status at 2 hours 3
  • Number needed to treat (NNT) for 200mg dose: 8 for headache relief and 13 for pain-free status 3

• Naproxen (500-550mg)

  • Recommended as a first-line acute treatment alongside ibuprofen 1
  • Particularly useful when longer duration of action is needed due to its extended half-life

Comparative Efficacy

Diclofenac-potassium has shown advantages over other options:

• Provides faster onset of analgesic effect than oral sumatriptan
• More effective at reducing accompanying symptoms, particularly nausea
• Better tolerability profile compared to sumatriptan 2

Administration Considerations

• For optimal effectiveness, NSAIDs should be administered at the onset of migraine pain 4
• Consider adding metoclopramide (10mg) or domperidone 20-30 minutes before or with NSAIDs to improve absorption and reduce nausea 4, 5
• For severe attacks unresponsive to oral medications, consider:
  • Intravenous acetylsalicylic acid
  • Ketorolac (60mg IM every 15-30 minutes, max 120mg/day) 4, 5
  • IV ibuprofen (800mg) has shown promise in reducing pain and associated symptoms 6

Treatment Strategy

1. For mild to moderate attacks:

   • Start with oral NSAIDs (ibuprofen 400-800mg or naproxen 500-550mg)
   • Consider adding an antiemetic if nausea is present

2. For moderate to severe attacks or those unresponsive to NSAIDs:

   • Consider triptans (sumatriptan, rizatriptan, etc.) 5, 7
   • Avoid using compounds containing butalbital or opiates due to risk of progression to chronic migraine 7

Cautions and Contraindications

• Avoid NSAIDs in patients with:

  • NSAID-induced asthma
  • Pregnancy
  • Gastrointestinal bleeding risk
  • Significant renal impairment 4

• Limit acute medications to ≤10 days per month to prevent medication overuse headache 1

Key Points for Clinical Practice

• Use NSAIDs early in the migraine attack for maximum effectiveness
• The concept of stratified treatment should guide medication selection based on attack severity
• For frequent migraine (>10 days/month), limit acute treatments to only the most disabling episodes 7
• Consider preventive treatment if using rescue medication more than twice weekly 1

Remember that while NSAIDs are effective for acute treatment, patients with frequent migraines may require prophylactic therapy with medications like propranolol, topiramate, or amitriptyline 1, 5.