What is the recommended treatment for migraines in non-pregnant adults?

Treatment of Migraine for Non-Pregnant Adults

For acute migraine treatment in non-pregnant adults, first-line therapy should be a combination of a triptan with a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen for moderate to severe attacks, while mild attacks can be treated with NSAIDs or acetaminophen alone. 1

Acute Treatment Algorithm

Step 1: Initial Treatment Based on Severity

• Mild attacks:

  • NSAID (aspirin, celecoxib, diclofenac, ibuprofen, or naproxen)
  • Acetaminophen
  • Combination of NSAID and acetaminophen 1, 2

• Moderate to severe attacks:

  • Start with an NSAID or acetaminophen
  • If inadequate response, add a triptan to the NSAID or acetaminophen 1

Step 2: For Patients Who Don't Respond to Step 1

• Try a CGRP antagonist-gepant (rimegepant, ubrogepant, or zavegepant)
• Or try dihydroergotamine 1

Step 3: For Patients Who Don't Respond to Steps 1 and 2

• Consider the ditan lasmiditan 1

Specific Medication Recommendations

NSAIDs

• Ibuprofen 400-800mg
• Naproxen sodium
• Aspirin 800-1000mg (often combined with metoclopramide 10mg for nausea) 2, 3

Triptans

• Options include: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan
• Choice depends on patient preferences, route of administration, and cost 1
• For patients with severe nausea/vomiting, consider non-oral triptans (nasal, injectable) with an antiemetic 1

Important Clinical Considerations

Timing of Treatment

• Begin treatment as soon as possible after migraine onset
• Early intervention with combination therapy improves efficacy 1

Medication Overuse Risk

• Monitor for medication overuse headache, defined as headaches occurring ≥15 days/month for ≥3 months due to overuse of acute medication
• Risk thresholds: ≥15 days/month with NSAIDs; ≥10 days/month with triptans 1

Contraindications and Cautions

• Triptans: Contraindicated in patients with cerebrovascular disease, coronary artery disease, uncontrolled hypertension, or hemiplegic migraine 2, 4
• NSAIDs: Use caution in patients with gastrointestinal, renal, or cardiovascular disease
• Opioids and butalbital: Should not be used for acute migraine treatment 1

Special Populations

• Women with migraine with aura: Higher risk of ischemic stroke; combined hormonal contraceptives containing estrogen are contraindicated 2
• Pregnancy considerations: Discuss adverse effects of medications during pregnancy and lactation 1
• Elderly patients: Start at lower doses due to potential for decreased hepatic, renal, or cardiac function 4

Non-Pharmacological Approaches

• Regular sleep schedule
• Stress management techniques
• Regular moderate to intense aerobic exercise
• Maintaining hydration and regular meals
• Weight loss for overweight/obese patients 1, 2

Prevention Considerations

For patients with frequent migraine attacks or inadequate response to acute treatment, consider preventive therapy 1:

1. First-line preventive options:

   • Beta-blockers (metoprolol or propranolol)
   • Valproate
   • Venlafaxine
   • Amitriptyline 1

2. Second-line preventive options:

   • CGRP antagonists-gepants (atogepant or rimegepant)
   • CGRP monoclonal antibodies (eptinezumab, erenumab, fremanezumab, or galcanezumab) 1

3. Third-line preventive option:

   • Topiramate 1

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

   • OnabotulinumtoxinA (Botox) injections 2, 5

The stratified care approach (matching treatment intensity to migraine severity) has been shown to provide better clinical outcomes than step care strategies, with improved headache response and reduced disability time 6.