What are the guidelines for treating migraines?

Migraine Treatment Guidelines

For optimal management of migraine, NSAIDs should be used as first-line abortive treatment, with triptans as second-line therapy, while preventive treatment should be initiated for patients experiencing ≥2 migraines per month with disability lasting ≥3 days or when acute treatments are ineffective. 1

Acute Treatment Strategies

First-Line Treatment (Mild to Moderate Attacks)

• NSAIDs:
  • Ibuprofen: 400-800 mg every 6 hours (maximum 2.4g daily)
  • Naproxen sodium: 275-550 mg every 2-6 hours (maximum 1.5g daily)
  • Aspirin: 650-1000 mg every 4-6 hours (maximum 4g daily) 1
• Combination therapy:
  • Aspirin-acetaminophen-caffeine (e.g., Excedrin Migraine) shows significant improvement in pain freedom at 2 hours (NNT of 9) and pain relief at 2 hours (NNT of 4) 1

Second-Line Treatment (Moderate to Severe Attacks)

• Triptans:
  • Sumatriptan: 50 mg orally or 6mg subcutaneously for severe attacks with significant nausea/vomiting
  • Rizatriptan: 10mg orally for adolescents weighing ≥40kg, 50 mg for most adults 1
  • Other options: zolmitriptan, almotriptan, frovatriptan, naratriptan 2

For Refractory Attacks

• Combination therapy: Use triptans and NSAIDs simultaneously 2
• Gepants: (e.g., Ubrelvy) for patients who cannot take triptans due to contraindications or tolerability issues 1
• Antiemetics: Metoclopramide (Reglan) or Prochlorperazine (Compazine) for accompanying nausea 1
• Rescue medications: Dopamine antagonists, combination analgesics, and corticosteroids when usual medications fail 2

Preventive Treatment

When to Consider Prevention

• Migraines occurring ≥2 times per month with disability lasting ≥3 days
• Acute treatments are ineffective, contraindicated, or overused
• Significant impact on quality of life despite acute treatment 1

First-Line Preventive Medications

• Beta-blockers:
  • Propranolol (80-240 mg/day)
  • Timolol (20-30 mg/day)
  • Metoprolol 1
• Anticonvulsants:
  • Topiramate (25-100 mg/day)
  • Divalproex sodium (500-1000 mg/day) 1
• Antidepressants:
  • Amitriptyline (30-150 mg/day) 1

Newer Preventive Options

• CGRP Antagonists:
  • Galcanezumab (Emgality): 240 mg loading dose followed by 120 mg monthly 3
  • Erenumab (Aimovig): Indicated for preventive treatment of migraine in adults 4

Complementary Treatments

• Magnesium or riboflavin supplementation as adjunctive treatments 1
• Petasites and feverfew have evidence supporting effectiveness 5

Medication Limitations and Contraindications

Medication Overuse Prevention

• Sumatriptan: No more than 9 days per month
• OTC medications: No more than 14 days per month
• NSAIDs: No more than 15 days per month
• Gepants (e.g., Ubrelvy): No more than 8 days per month 1

Contraindications

• Triptans: Contraindicated in patients with:

  • Cardiovascular conditions
  • Wolff-Parkinson-White syndrome
  • History of stroke/TIA
  • Peripheral vascular disease
  • Uncontrolled hypertension
  • Recent use of another triptan or ergotamine
  • Concurrent use of MAO inhibitors 1

• Opioids and butalbital-containing medications: Should be avoided due to questionable efficacy and risk of dependence 1

Lifestyle Modifications

• Maintain regular sleep schedule
• Eat regular meals
• Engage in moderate aerobic exercise
• Manage stress with relaxation techniques or mindfulness practices
• Track headache patterns using a diary to identify triggers 1

Special Populations

Children and Adolescents

• Ibuprofen is recommended to treat pain in children/adolescents
• For adolescents, consider sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral 6
• If one triptan is ineffective, try another or a NSAID-triptan combination 6
• For prevention in children/adolescents, consider amitriptyline combined with cognitive behavioral therapy, topiramate, or propranolol 6

Pregnancy and Breastfeeding

• Acetaminophen is the safest acute migraine drug during pregnancy
• Acetaminophen with codeine is also an option during pregnancy
• Sumatriptan may be an option during pregnancy for selected patients and is compatible with breastfeeding 2

Follow-up and Monitoring

• Schedule follow-up in 4-6 weeks to assess effectiveness of preventive therapy
• Use headache diary to track frequency, severity, and medication use
• Consider referral to neurologist or headache specialist if no improvement after trials of 2-3 preventive medications 1
• Evaluate for high-risk factors including anxiety, depression, and medication overuse 1

Common Pitfalls to Avoid

• Delaying treatment during an attack (treat early for best results) 6
• Overusing acute medications leading to medication overuse headache
• Failing to address lifestyle factors and triggers
• Not considering preventive therapy when indicated
• Using opioids as first-line treatment
• Not adjusting treatment based on attack severity and individual response