Treatment Options for Migraine
For migraine treatment, a combination of a triptan with a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen is the first-line therapy for moderate to severe attacks, while NSAIDs or acetaminophen alone are recommended for mild attacks. 1
Acute Migraine Treatment
First-Line Options Based on Severity
Mild attacks:
- NSAIDs (aspirin, celecoxib, diclofenac, ibuprofen, naproxen)
- Acetaminophen
- Aspirin-acetaminophen-caffeine combination (strongly recommended) 1
Moderate to severe attacks:
- Start with NSAID or acetaminophen
- Add a triptan if inadequate response
- Combination therapy is more effective than monotherapy 1
Triptan Selection
- Options include sumatriptan, almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, or zolmitriptan
- Clinical trials show sumatriptan is effective with 50-62% of patients achieving headache response within 2 hours and 65-79% within 4 hours 2
- For patients with nausea/vomiting, consider non-oral triptans (nasal, injectable) with an antiemetic 1
Second-Line Options
- CGRP antagonists (rimegepant, ubrogepant, zavegepant)
- Dihydroergotamine
- Lasmiditan (a ditan) 1
Preventive Treatment for Episodic Migraine
First-Line Preventive Medications
- Beta-blockers (metoprolol, propranolol)
- Valproate/divalproex sodium
- Venlafaxine
- Amitriptyline 1
Second-Line Preventive Options
- CGRP antagonists (atogepant, rimegepant)
- CGRP monoclonal antibodies (eptinezumab, erenumab, fremanezumab, galcanezumab) 1
Third-Line Preventive Option
- Topiramate 1
Additional Options (if first-line not tolerated or ineffective)
- ACE inhibitor (lisinopril)
- ARBs (candesartan, telmisartan)
- SSRI (fluoxetine) 3
Non-Pharmacological Approaches
Lifestyle Modifications
- Identify and avoid migraine triggers
- Maintain regular sleep, eating, and physical activity habits
- Stay hydrated 3, 1
Evidence-Based Non-Pharmacological Treatments
- Cognitive behavioral therapy
- Relaxation training
- Mindfulness-based treatment
- Regular aerobic exercise (as effective as relaxation therapy or topiramate)
- Oral magnesium (400-600mg daily) 1
Important Clinical Considerations
Timing of Treatment
- Begin treatment as early as possible after migraine onset
- Early intervention improves efficacy 1
Medication Overuse Warning
- Monitor for medication overuse headache (≥15 days/month for ≥3 months)
- Risk thresholds: ≥15 days/month with NSAIDs, ≥10 days/month with triptans 1
Contraindications
- Triptans: contraindicated in cerebrovascular disease, coronary artery disease, uncontrolled hypertension, or hemiplegic migraine 1, 2
- NSAIDs: use with caution in GI, renal, or cardiovascular disease 1
- Women with migraine with aura: combined hormonal contraceptives with estrogens are contraindicated due to increased stroke risk 1
Dosing Considerations
- Start preventive medications at a low dose and gradually increase until desired outcomes are achieved 3
- Consider a 2-3 month trial period before switching preventive medications 3
Monitoring
- Use a headache diary to track frequency, severity, medication use, and response to treatment 3, 1
- Regularly reevaluate the need for continued preventive treatment 3
Special Populations
Women of Childbearing Potential
- Discuss adverse effects of medications during pregnancy and lactation 3
- Women with migraine with aura have significantly higher risk of ischemic stroke (RR 2.08) 1
Patients with Frequent Attacks
- Consider preventive therapy for patients with severe debilitating headaches despite adequate acute treatment 3
- Consider preventive therapy for patients unable to tolerate acute treatments or using them more often than recommended 3
By following this treatment approach and considering individual patient factors, most migraine patients can achieve significant improvement in their condition.