What are the treatment options for migraines?

Migraine Treatment Options

For acute migraine treatment, start with NSAIDs or acetaminophen for mild to moderate attacks, and add a triptan if inadequate response occurs. For moderate to severe attacks, begin with combination therapy of a triptan plus an NSAID or acetaminophen. 1

Acute Treatment Algorithm

First-Line Options:

1. Mild to Moderate Attacks:

   • NSAIDs (aspirin, celecoxib, diclofenac, ibuprofen, or naproxen) 1
   • Acetaminophen (when NSAIDs are contraindicated) 1
   • Combination of NSAID + acetaminophen 1

2. Moderate to Severe Attacks:

   • Triptan + NSAID combination (e.g., sumatriptan 50-100mg + naproxen) 1, 2
   • Triptan + acetaminophen (when NSAIDs are contraindicated) 1

Second-Line Options (for inadequate response to first-line):

• CGRP antagonists-gepants (rimegepant, ubrogepant, zavegepant) 1
• Ergot alkaloid (dihydroergotamine) 1
• Ditan lasmiditan (for patients who don't respond to all other treatments) 1

For Severe Nausea/Vomiting:

• Non-oral triptan formulation (nasal spray, injection) + antiemetic 1

Important Considerations for Acute Treatment

• Begin treatment as early as possible after migraine onset for better efficacy 1
• Avoid opioids and butalbital for acute migraine treatment 1
• Medication overuse headache risk: Limit acute medications to ≤10 days/month for triptans and ≤15 days/month for NSAIDs 1, 2
• Sumatriptan contraindications: Coronary artery disease, Prinzmetal's variant angina, uncontrolled hypertension, history of stroke/TIA, and concurrent MAO-A inhibitor use 3, 4
• Serotonin syndrome risk: Use caution when combining triptans with SSRIs or SNRIs 3, 4

Preventive Treatment

Consider preventive therapy for patients with:

• ≥4 headache days per month
• Significant disability despite acute treatment
• Contraindications to acute medications
• Medication overuse headache risk 2, 5

First-Line Preventive Options:

• Beta-blockers: Propranolol (80-240 mg/day), timolol (20-30 mg/day) 2
• Anticonvulsants: Topiramate (100 mg/day), divalproex sodium (500-1500 mg/day) 2
• Antidepressants: Amitriptyline (30-150 mg/day) 2
• Angiotensin receptor blockers: Candesartan (8-32 mg/day) 2

Complementary Preventive Options:

• Magnesium (400-600 mg daily)
• Riboflavin (400 mg daily)
• Coenzyme Q10 2

Lifestyle Modifications

• Maintain regular sleep schedule
• Stay well hydrated
• Identify and avoid personal triggers using a headache diary
• Engage in regular aerobic exercise
• Practice stress management techniques 1, 2

Treatment Evaluation and Monitoring

• Use a headache diary to track frequency, severity, and response to treatment 2
• Evaluate response to preventive medications after 2-3 months of treatment 2
• Target goal for preventive treatment is a 50% reduction in attack frequency 2
• If inadequate response to first preventive medication after 6-8 weeks, switch to another first-line agent 2

Special Populations

Pregnancy and Breastfeeding:

• Acetaminophen is the safest acute option during pregnancy 6
• Discuss adverse effects of medications during pregnancy and lactation 1

Cardiovascular Risk:

• Avoid triptans in patients with coronary artery disease, uncontrolled hypertension, or history of stroke 3, 4
• Consider non-vasoconstricting options like NSAIDs, acetaminophen, or neuromodulation 7

By following this evidence-based approach to migraine treatment, patients can experience significant reduction in migraine frequency, severity, and associated disability, ultimately improving their quality of life.