What are the treatment options for migraine?

Migraine Treatment Options

The most effective approach to migraine management involves both acute treatment with triptans or NSAIDs and preventive therapy with beta-blockers, anticonvulsants, or CGRP antagonists for patients with frequent attacks. 1

Acute Treatment Options

First-Line Options

• Mild to Moderate Migraines:

  • NSAIDs: ibuprofen 400-800mg, naproxen sodium 500-550mg, diclofenac potassium, or aspirin 1000mg 1
  • Acetaminophen 1000mg (if NSAIDs contraindicated) 1

• Moderate to Severe Migraines:

  • Oral triptans (sumatriptan, rizatriptan, eletriptan) - first-line treatment 1
    • Sumatriptan shows significant headache response within 2 hours (50-62% efficacy vs 17-27% for placebo) 2
    • Combining triptan + acetaminophen provides better relief than either alone 1

• For Patients with Nausea/Vomiting:

  • Non-oral formulations (nasal sprays, injections) of triptans 1
  • Add antiemetic (e.g., metoclopramide 10mg) 1

Second-Line Options

• CGRP antagonists (gepants): rimegepant, ubrogepant, zavegepant - for patients who don't respond to or tolerate triptans 1

Important Cautions

• Limit acute medications to no more than 2 days per week to prevent medication-overuse headache 1
• Triptans are contraindicated in patients with:
  • Coronary artery disease
  • Uncontrolled hypertension
  • History of stroke
  • Wolff-Parkinson-White syndrome or cardiac accessory conduction pathway disorders 2
• Avoid opioids and butalbital-containing medications due to risk of medication overuse headache and dependence 1

Preventive Treatment Options

Indications for Preventive Therapy

• Frequent headaches (typically ≥4 attacks per month)
• Attacks that significantly interfere with daily activities despite acute treatment
• Contraindication to or failure of acute treatments
• Medication overuse headache 1, 3

First-Line Preventive Options

• Beta-blockers:

  • Propranolol 80-240 mg/day
  • Timolol 20-30 mg/day 1

• Anticonvulsants:

  • Topiramate 100 mg/day (titrate slowly to minimize side effects)
  • Divalproex sodium 500-1500 mg/day
  • Sodium valproate 800-1500 mg/day 1

• CGRP monoclonal antibodies:

  • Erenumab, fremanezumab, galcanezumab
  • Monthly or quarterly injections
  • Well-tolerated with minimal drug interactions 1

Second-Line Preventive Options

• Antidepressants:

  • Amitriptyline 30-150 mg/day (also helps with sleep disturbances) 1
  • Venlafaxine 3

• OnabotulinumtoxinA (Botox):

  • FDA-approved for chronic migraine prophylaxis
  • Particularly useful for patients with medication overuse headache 1, 3

• Angiotensin receptor blockers:

  • Candesartan or telmisartan 1

Special Populations

Women of Childbearing Age

• Women with migraine with aura should avoid combined hormonal contraceptives with estrogens due to increased stroke risk 1
• Topiramate and valproate have teratogenic effects; effective birth control methods and folate supplementation are advised 1

Adolescents

• Consider sumatriptan/naproxen, zolmitriptan nasal spray, sumatriptan nasal spray, rizatriptan ODT, or almotriptan 1

Non-Pharmacological Approaches

Lifestyle Modifications

• Regular sleep schedule
• Stress management techniques
• Regular physical activity
• Adequate hydration and regular meals 1

Supplements

• Magnesium (400-600 mg daily) - most evidence-supported supplement for migraine prevention 1
• Riboflavin (vitamin B2) and Coenzyme Q10 may also be considered 1

Behavioral Therapies

• Cognitive-behavioral therapy (CBT)
• Biofeedback
• Regular aerobic exercise (as effective as relaxation therapy or topiramate in randomized controlled trials) 1

Treatment Algorithm

1. For acute attacks:

   • Mild to moderate: Start with NSAIDs or acetaminophen
   • Moderate to severe: Use triptan or triptan + NSAID/acetaminophen
   • If significant nausea/vomiting: Use non-oral formulations and add antiemetic

2. For prevention (if ≥4 attacks/month or significant disability):

   • First trial: Beta-blocker (propranolol) or anticonvulsant (topiramate)
   • If ineffective after 6-8 weeks: Switch to different class or add CGRP monoclonal antibody
   • If still inadequate: Consider onabotulinumtoxinA or referral to headache specialist

3. Always incorporate:

   • Lifestyle modifications
   • Trigger identification and avoidance
   • Consider supplements (magnesium, riboflavin)

Monitoring

• Use a headache diary to track frequency, severity, and medication use
• Assess effectiveness of preventive treatment after 6-8 weeks at therapeutic doses 1
• Consider specialist referral if two or more preventive medication trials fail, diagnosis uncertainty exists, or complex comorbidities are present 1