What is the treatment for migraines?

Treatment of Migraines

For migraine treatment, a two-pronged approach using both acute medications (aspirin-acetaminophen-caffeine combinations, NSAIDs, or triptans) for immediate relief and prophylactic medications (propranolol, amitriptyline, topiramate, or CGRP antagonists) for prevention is recommended for patients experiencing ≥2 migraine days per month despite optimized acute treatment. 1

Acute Treatment

First-Line Options

• For mild to moderate migraines:

  • Aspirin-acetaminophen-caffeine combination (strong recommendation) 1
  • NSAIDs: Ibuprofen 400-800mg or Naproxen sodium 1

• For moderate to severe migraines:

  • Triptans (sumatriptan, rizatriptan, zolmitriptan, naratriptan) 1, 2
    • Sumatriptan shows significant headache relief at 2 hours (50-62% response rate vs 17-27% for placebo) 2
    • Dosing: 25mg, 50mg, or 100mg with similar efficacy; 100mg associated with more adverse events 2
  • Treat attacks early for better efficacy 1

Alternative Acute Options

• Ubrogepant and rimegepant (Gepants) - moderate effects with NNT of 13 for pain freedom at 2 hours 1
• Lasmiditan (Ditans) - effective but has significant adverse effects including driving restrictions 1

Prophylactic Treatment

First-Line Options

• Beta-blockers:

  • Propranolol 80-240 mg/day (FDA-approved for migraine prophylaxis) 1, 3
  • Timolol 20-30 mg/day 1

• Antidepressants:

  • Amitriptyline 30-150 mg/day (contraindicated in heart failure and glaucoma) 1

• Anticonvulsants:

  • Divalproex sodium 500-1500 mg/day 1
  • Sodium valproate 800-1500 mg/day 1
  • Topiramate 100 mg/day (start at 25mg daily and gradually increase) 1

• Angiotensin receptor blockers:

  • Candesartan 16-32mg daily (better tolerated than beta-blockers in patients with asthma or depression) 1

Second-Line Options

• OnabotulinumtoxinA (Botox) 1
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1
• Flunarizine 5-10mg daily (contraindicated in parkinsonism and depression) 1

Treatment Evaluation and Monitoring

• Define treatment success as ≥50% reduction in monthly migraine episodes 1
• Assess efficacy after 2-3 months of optimized therapy 1
• If first medication fails, switch to an alternative first-line agent 1
• If second trial fails, consider CGRP monoclonal antibodies or onabotulinumtoxinA 1
• Maintain a headache diary to identify triggers and track frequency, severity, and medication use 1

Lifestyle Modifications and Supplements

• Regular aerobic exercise, consistent sleep schedule, adequate hydration, regular meals 1
• Stress management techniques 1
• Oral magnesium 400-600mg daily (most evidence-supported supplement) 1

Important Precautions

• Triptans are contraindicated in patients with coronary artery disease, stroke, TIA, hemiplegic or basilar migraine, peripheral vascular disease, or uncontrolled hypertension 1
• Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk 1
• Limit acute treatments to a maximum of 10 days per month to prevent medication-overuse headache 4
• For status migrainosus, parenteral steroids and fluid replacement are recommended 4

Special Populations

• Pregnancy: Acetaminophen is the first choice 4
• Children: Acetaminophen is the first choice 4
• Avoid opiates for acute migraine treatment due to serious adverse events 4