What are the treatment options for migraine?

Treatment Options for Migraine

Migraine management should follow a structured approach with oral triptans as first-line acute treatment for moderate-to-severe attacks, NSAIDs for mild attacks, and beta-blockers or anticonvulsants as first-line preventive options when indicated. 1

Acute Treatment Options

First-Line Treatments

• For mild to moderate attacks:

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

• For moderate to severe attacks:

  • Oral triptans (sumatriptan, rizatriptan, eletriptan) - most effective when taken early in attack 1, 2
  • Combination therapy (triptan + acetaminophen) provides better relief than either medication alone 1

Special Formulations

• For patients with significant nausea/vomiting:
  • Non-oral triptan formulations (nasal sprays, injections) 1
  • Add antiemetic (e.g., metoclopramide 10mg) 1

Second-Line Options

• For patients who don't respond to or tolerate triptans:
  • CGRP antagonists (gepants): rimegepant, ubrogepant, zavegepant 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, or history of stroke 1, 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)
• Significant disability despite acute treatment
• Contraindication to or failure of acute treatments
• Medication overuse headache
• Patient preference 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) 1

Second-Line Preventive Options

• Antidepressants:

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

• Angiotensin receptor blockers:

  • Candesartan, telmisartan 1

• For chronic migraine:

  • OnabotulinumtoxinA (Botox) - particularly useful for patients with medication overuse headache 1, 3

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 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 some studies) 1

Treatment Algorithm

1. Assess migraine severity and frequency

2. For acute treatment:

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

3. For preventive treatment (if indicated):

   • Start with beta-blocker (propranolol) or anticonvulsant (topiramate)
   • Assess effectiveness after 6-8 weeks at therapeutic doses
   • If inadequate response, switch to different preventive medication or add CGRP monoclonal antibody
   • Consider specialist referral if two or more preventive medication trials fail

4. Always incorporate lifestyle modifications and non-pharmacological approaches

Common Pitfalls to Avoid

• Overuse of acute medications leading to medication-overuse headache
• Using triptans in patients with cardiovascular contraindications
• Inadequate dosing or premature discontinuation of preventive medications
• Failure to address triggers and lifestyle factors
• Delayed treatment of acute attacks (sumatriptan is most effective when taken early) 1, 2