What are the recommended treatments for migraine management?

Migraine Management: Recommended Treatments

The American Academy of Neurology recommends propranolol (80-240 mg/day) as a first-line preventive treatment for migraine, while aspirin-acetaminophen-caffeine combination, ibuprofen 400-800mg, and naproxen sodium are recommended as first-line acute treatments for migraine. 1

Acute Treatment of Migraine

First-Line Options

• Non-specific treatments:
  • Aspirin-acetaminophen-caffeine combination
  • Ibuprofen 400-800mg
  • Naproxen sodium
  • These medications have strong recommendations from the American College of Physicians 1

Second-Line Options (Migraine-Specific)

• Triptans:

  • Sumatriptan: Available in 25mg, 50mg, and 100mg doses
    • 50mg and 100mg doses provide greater effect than 25mg
    • Maximum daily dose: 200mg in 24 hours 2
    • Second dose may be taken if migraine hasn't resolved after 2 hours 2
  • Rizatriptan
  • Zolmitriptan
  • Naratriptan

• Newer agents (for those who fail triptans):

  • Gepants (Ubrogepant, Rimegepant) - advantage of no vascular contraindications 1, 3
  • Ditans (Lasmiditan) - effective for pain freedom but has significant adverse effects 1

Special Considerations for Acute Treatment

• For patients with hepatic impairment, maximum single dose of sumatriptan should not exceed 50mg 2
• Triptans are contraindicated in patients with vascular disease 3
• Avoid opioids and butalbital-containing medications unless other options have failed 3

Preventive Treatment of Migraine

First-Line Preventive Medications

• Beta-blockers:

  • Propranolol (80-240 mg/day)
  • Timolol (20-30 mg/day)

• Antidepressants:

  • Amitriptyline (30-150 mg/day)

• Anticonvulsants:

  • Divalproex sodium (500-1500 mg/day)
  • Sodium valproate (800-1500 mg/day)
  • Topiramate (100 mg/day)

Second-Line and Specialized Preventive Options

• OnabotulinumtoxinA (Botox)
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab)
• Angiotensin receptor blockers (candesartan/telmisartan)
• Eptinezumab (100mg every 3 months, can be escalated to 300mg if inadequate response) 1

When to Consider Preventive Treatment

• Frequent migraine attacks (typically >4 per month)
• Attacks significantly impacting quality of life despite acute treatment
• Contraindications to acute treatments
• Risk of medication overuse headache

Non-Pharmacological Approaches

Lifestyle Modifications

• Maintain regular sleep, eating, and work habits 1, 4, 5
• Identify and avoid personal migraine triggers 4, 5
• Regular aerobic exercise (as effective as relaxation therapy or topiramate in some studies) 1
• Weight management (obesity is a modifiable risk factor) 1, 4

Supplements and Alternative Therapies

• Oral magnesium (400-600mg daily) - most evidence-supported supplement 1
• Cognitive-behavioral therapy (CBT) and biofeedback 1

Special Populations and Considerations

Women with Migraine

• Women with migraine with aura have significantly higher risk of ischemic stroke (relative risk 2.08) 1
• Combined hormonal contraceptives with estrogens are contraindicated in women with migraine with aura 1

Cautions with Medications

• Beta-blockers should be used cautiously in patients with asthma, diabetes, heart block, or bradycardia 1
• Monitor for medication overuse headache with frequent use of acute treatments 1, 6

When to Refer to a Specialist

• Failure of two or more preventive medication trials
• Uncertain diagnosis
• Complex comorbidities
• Need for advanced treatments like onabotulinumtoxinA 1

Monitoring Treatment Response

• Maintain a headache diary to track:
  • Frequency and severity of attacks
  • Medication use and effectiveness
  • Potential triggers 1
• Evaluate treatment response after 2-3 months of preventive therapy 1