What are the treatment options for migraine headaches?

Migraine Headache Treatment Options

The most effective approach to migraine management combines both acute treatment and preventive therapy, with first-line acute treatments including NSAIDs for mild to moderate attacks and triptans for moderate to severe attacks, while first-line preventive options include beta-blockers, topiramate, amitriptyline, and valproate for patients experiencing frequent migraines. 1, 2

Pathophysiology

Migraine is a primary headache disorder characterized by recurrent attacks, affecting approximately 12% of the population 3. The pathophysiology involves:

• Trigeminal sensory activation causing headache pain
• Spreading depolarization likely causing aura symptoms
• Contrary to older theories, vasodilation is only a secondary phenomenon 4

Assessment and Diagnosis

When evaluating patients with suspected migraines, ask about:

• Frequency, duration, and intensity of headaches
• Character of pain (throbbing, dull, etc.)
• Associated symptoms (nausea, vomiting, photophobia, phonophobia)
• Location of pain (unilateral, bilateral)
• Triggers (stress, foods, hormonal changes, etc.)
• Response to previous treatments 5

Acute Treatment Options

Mild to Moderate Attacks

• First-line: NSAIDs and acetaminophen
  • Ibuprofen, diclofenac, aspirin
  • Take early in the attack for best results 2

Moderate to Severe Attacks

• First-line: Triptans (5-HT1B/1D receptor agonists)
  • Sumatriptan (available in oral, nasal, and injectable forms)
  • Most effective when taken early while headache is still mild
  • Oral sumatriptan 50-100mg shows significant headache response at 2 hours (50-62% response) and 4 hours (68-79% response) 6
  • Do not use during aura phase 1
  • For patients with severe nausea/vomiting, consider non-oral formulations 1

Second-line Options

• Antiemetics with prokinetic properties (for associated nausea)
• Ditans (lasmiditan)
• CGRP antagonists (gepants: ubrogepant, rimegepant) 1, 4

Third-line Options

• Dihydroergotamine (DHE)
• Combination analgesics 2

Preventive Treatment

When to Consider Prevention

Preventive therapy should be considered if the patient has:

• More than two headaches per week
• Attacks causing significant disability
• Poor response to acute treatments
• Risk of medication overuse headache 5, 1

First-line Preventive Options

• Beta-blockers: Propranolol (80-240 mg/day), timolol (20-30 mg/day)
• Anticonvulsants: Topiramate (100 mg/day), valproate (800-1500 mg/day)
• Antidepressants: Amitriptyline (30-150 mg/day)
• Angiotensin receptor blockers: Candesartan 1, 7, 8

Second-line Preventive Options

• OnabotulinumtoxinA (Botox) - particularly for chronic migraine
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab)
• CGRP antagonists (atogepant, rimegepant) 1, 4

Evidence-based Supplements

• Magnesium (400-600mg daily)
• Riboflavin (vitamin B2)
• Coenzyme Q10
• Butterbur 1, 7, 8

Non-pharmacological Approaches

Lifestyle Modifications (for all migraine patients)

• Regular sleep schedule
• Regular meal times (avoid skipping meals)
• Adequate hydration
• Stress management techniques
• Regular physical activity 1

Other Non-pharmacological Options

• Cognitive-behavioral therapy
• Biofeedback
• Relaxation therapy
• Aerobic exercise
• Acupuncture 1, 7, 8

Medication Overuse Headache Prevention

• Limit acute medications to ≤2 days per week or ≤10 days per month
• Frequent use of some migraine medications (ergotamine, opiates, analgesics, triptans) may cause medication-overuse headaches
• For patients with medication overuse, withdrawal of overused medication is necessary, with abrupt withdrawal preferred for most medications except opioids 5, 1

Special Considerations

• Women with migraine with aura are at higher risk of ischemic stroke and should avoid combined hormonal contraceptives with estrogens
• Beta-blockers should be used cautiously in patients with asthma, diabetes, heart block, or bradycardia
• NSAIDs should be used with caution in patients with gastrointestinal, renal, or cardiovascular disease 1

When to Consider Neuroimaging

Neuroimaging should be considered in patients with:

• Unexplained abnormal neurological examination
• Neurologic symptoms (headache worsened with Valsalva, awakens from sleep, new onset in older person, progressively worsening)
• Atypical features not meeting strict definition of migraine 5

When to Refer to a Specialist

Consider specialist referral for:

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