First-Line Treatment for Migraine
The first-line treatment for acute migraine is over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), specifically acetylsalicylic acid (aspirin), ibuprofen, or diclofenac potassium. 1
Treatment Algorithm for Acute Migraine
First-Line Therapy (Mild to Moderate Migraine)
- NSAIDs with strongest evidence:
- Acetylsalicylic acid (aspirin)
- Ibuprofen
- Diclofenac potassium
- Alternative if NSAID intolerant:
- Paracetamol/acetaminophen (less efficacious than NSAIDs) 1
Second-Line Therapy (Inadequate Response to NSAIDs or Moderate to Severe Migraine)
- Triptans:
- Most effective when taken early in an attack while pain is still mild 1
- Options include sumatriptan (available in various formulations)
- Dosing: 25mg, 50mg, or 100mg orally (50mg and 100mg may provide greater effect than 25mg) 2
- Maximum daily dose: 200mg in a 24-hour period 2
- For patients with rapid peak headache intensity or vomiting, subcutaneous sumatriptan injection may be useful 1
Third-Line Therapy (Triptan Failure)
- If triptans fail after adequate trial (no response in at least three consecutive attacks) or are contraindicated, limited alternatives are available 1
Important Clinical Considerations
Medication Administration Timing
- Triptans are most effective when taken early in an attack while pain is still mild 1
- Do not use triptans during the aura phase of a migraine attack 1
Managing Relapse
- For relapse (return of symptoms within 48 hours after successful treatment), patients can:
- Repeat triptan treatment
- Combine triptan with fast-acting NSAIDs (naproxen sodium, ibuprofen lysine, or diclofenac potassium) 1
- Caution: Repeated treatment increases risk of medication overuse headache 1
Hepatic Impairment Considerations
- For patients with mild to moderate hepatic impairment, maximum single dose of sumatriptan should not exceed 50mg 2
Medication Overuse Prevention
- Limit use of simple analgesics to fewer than 15 days/month
- Limit triptans to fewer than 10 days/month 3
Preventive Treatment Considerations
For patients with frequent migraines (≥4 headaches/month), consider preventive therapy with:
- First-line preventive options:
- Propranolol (80-240 mg/day)
- Timolol (20-30 mg/day)
- Amitriptyline (30-150 mg/day)
- Divalproex sodium (500-1500 mg/day)
- Topiramate (100 mg/day) 3
Evidence Quality Assessment
The recommendations for first-line acute migraine treatment come from the 2021 Nature Reviews Neurology guideline 1, which represents the most recent high-quality evidence. This guideline clearly establishes NSAIDs (specifically acetylsalicylic acid, ibuprofen, and diclofenac potassium) as first-line treatments for acute migraine, with triptans as second-line options when NSAIDs provide inadequate relief.
The stepped care approach recommended in this guideline prioritizes both efficacy and safety, considering that overuse of acute medications can lead to medication overuse headache, a significant concern in migraine management.