What are the treatment options for migraines?

Treatment of Migraines

First-line treatments for acute migraine episodes include NSAIDs (ibuprofen or naproxen), acetaminophen, or a combination of NSAID + acetaminophen, with triptans (sumatriptan, rizatriptan, eletriptan) recommended for moderate to severe migraines. 1

Acute Treatment Algorithm

Step 1: Initial Treatment Based on Severity

• Mild to Moderate Migraines:

  • NSAIDs: Ibuprofen, naproxen, diclofenac potassium 1, 2
  • Acetaminophen (particularly safe during pregnancy) 1
  • Aspirin-acetaminophen-caffeine combination 1

• Moderate to Severe Migraines:

  • Triptans: Sumatriptan, rizatriptan, eletriptan 1, 3, 4
  • Triptan + NSAID combination (e.g., sumatriptan + naproxen) shows high efficacy 1
  • CGRP antagonists (gepants): Rimegepant, ubrogepant, zavegepant 1

Step 2: For Persistent Migraines

• If migraine persists >1 week after initial treatment and oral medications are ineffective, consider parenteral therapy 1
• Add antiemetic when nausea is prominent 1

Step 3: Refractory Migraines

• For patients not responding to NSAIDs or triptans alone, consider combination therapy (triptan + NSAID simultaneously) 5

Important Safety Considerations

• Medication Overuse Risk:

  • Limit NSAIDs to ≤15 days/month 1
  • Limit triptans to ≤10 days/month 1
  • Overuse can lead to medication overuse headache 4

• Triptan Contraindications:

  • Avoid in patients with cardiovascular disease, Wolff-Parkinson-White syndrome, or uncontrolled hypertension 1, 4
  • Use caution in patients with cardiovascular risk factors 1
  • Monitor for serotonin syndrome, especially when combined with SSRIs, SNRIs, TCAs, or MAOIs 4

Preventive Treatment

Consider preventive therapy for patients with ≥2 migraines per month, prolonged/disabling attacks, or reduced quality of life between attacks. 1

First-line Preventive Options:

• Beta-blockers: Propranolol (80-240 mg/day), Timolol (20-30 mg/day) 1
• Antidepressants: Amitriptyline (30-150 mg/day) 1
• Anticonvulsants: Topiramate (100 mg/day), Divalproex sodium (500-1500 mg/day) 1
• CGRP antagonists: Erenumab, fremanezumab, galcanezumab (for inadequate response after second injection) 1

Complementary Approaches:

• Magnesium supplements (400-600mg daily) 1
• Riboflavin supplements (400mg daily) 1
• Coenzyme Q10 supplements 1

Lifestyle Modifications

• Regular sleep schedule
• Consistent meal times
• Adequate hydration
• Regular physical activity
• Stress management techniques
• Identification and avoidance of personal triggers 1

Clinical Pearls

• Acetaminophen is the safest option during pregnancy 1, 5
• Triptans show superior efficacy compared to NSAIDs for moderate-severe attacks, but may be more expensive 6
• NSAIDs work through blocking cyclooxygenase and decreasing prostaglandin synthesis, which are involved in migraine pathophysiology 7
• OTC medications are appropriate first-line for mild-moderate attacks but patients with disability in >50% of attacks or vomiting in >20% of attacks should seek prescription options 8
• The efficacy of rizatriptan is unaffected by patient age, gender, or concomitant use of common migraine prophylactic drugs 3
• Target a 50% reduction in attack frequency for preventive therapy, allowing 6-8 weeks at therapeutic dose to assess effectiveness 1