Treatment Options for Migraine
For patients with migraine, a comprehensive approach including both acute and preventive treatments is recommended, with first-line preventive options including beta-blockers (propranolol 80-240 mg/day), topiramate (25-100 mg/day), and amitriptyline (30-150 mg/day), while acute treatment should utilize NSAIDs for mild attacks and triptans such as sumatriptan for moderate to severe attacks. 1, 2
Acute Treatment Options
First-Line Treatments
Mild to Moderate Attacks:
- NSAIDs (ibuprofen, naproxen)
- Acetaminophen
Moderate to Severe Attacks:
- Sumatriptan tablets: 50-100 mg (provides greater efficacy than 25 mg with similar side effect profile) 2
- Other triptans (rizatriptan, zolmitriptan, etc.)
Second-Line Treatments
- Antiemetics (for associated nausea)
- Dihydroergotamine (for refractory cases)
Important Considerations for Acute Treatment
- Take medication early in the attack for optimal efficacy 2
- If headache has not resolved after 2 hours, a second dose of sumatriptan may be administered (maximum 200 mg in 24 hours) 2
- Monitor for medication overuse headache if acute medications are used frequently
Preventive Treatment Options
When to Consider Prevention
- Migraine attacks exceeding 2 per month or causing significant disability 1
- Inadequate response to acute treatments
- Medication overuse concerns
First-Line Preventive Medications
Beta-blockers:
- Propranolol (80-240 mg/day)
- Timolol (20-30 mg/day)
- Metoprolol
Anticonvulsants:
- Topiramate (25-100 mg/day)
- Divalproex sodium (500-1500 mg/day)
- Sodium valproate (800-1500 mg/day)
Antidepressants:
- Amitriptyline (30-150 mg/day)
Angiotensin Receptor Blockers:
- Candesartan (8-32 mg/day)
Second-Line Preventive Options
- Venlafaxine (75-150 mg/day) - particularly helpful with comorbid insomnia 1
- Flunarizine (calcium channel blocker) - effective for hemiplegic migraine 1
- OnabotulinumtoxinA - specifically for chronic migraine 3
- CGRP monoclonal antibodies (erenumab, etc.) - newer options with good efficacy 3, 4
Non-Pharmacologic Interventions
Evidence-Based Supplements
- Riboflavin (Vitamin B2) 400 mg daily 1, 5
- Magnesium 400-600 mg daily 1, 5
- Coenzyme Q10 1, 3
- Petasites and feverfew 5
Behavioral Interventions
- Cognitive behavioral therapy
- Relaxation training
- Biofeedback
- Mindfulness-based treatment 1
Neuromodulation Options
- Transcutaneous electrical nerve stimulation
- Transcranial magnetic stimulation
- Vagal nerve stimulation 1
Lifestyle Modifications
- Regular sleep schedule
- Regular meals to prevent hypoglycemia-triggered headaches
- Moderate aerobic exercise (shown to reduce frequency and severity)
- Stress management techniques
- Adequate hydration
- Identification and avoidance of personal triggers 1
Treatment Evaluation and Adjustment
- Evaluate response after 6-8 weeks of preventive therapy
- Target goal: 50% reduction in headache frequency
- Consider referral to headache specialist if inadequate response after 2-3 months of appropriate therapy 1
Special Considerations
- Women with migraine with aura: Avoid combined hormonal contraceptives with estrogens due to increased stroke risk 1
- Pregnancy planning: Avoid topiramate and valproate due to teratogenic effects; ensure folate supplementation 1
- Comorbid conditions: Select preventive medications that may address multiple conditions (e.g., propranolol for hypertension, topiramate for weight management) 1
Common Pitfalls to Avoid
- Underutilizing preventive therapy (only 13% of eligible patients receive it) 5
- Inadequate dosing or duration of preventive medications
- Failing to address medication overuse, which can perpetuate headaches
- Not considering comorbidities when selecting treatments
- Neglecting non-pharmacologic approaches that have proven efficacy