What is the first line treatment for migraines?

First-Line Treatment for Migraines

NSAIDs (such as ibuprofen or naproxen), acetaminophen, or a combination of NSAID + acetaminophen are the first-line treatments for acute episodes of migraine. 1

Acute Treatment Algorithm

For Mild to Moderate Migraines:

• First-line options:
  • NSAIDs (ibuprofen 400-600mg or naproxen 500-550mg)
  • Acetaminophen 1000mg
  • Combination of NSAID + acetaminophen

For Moderate to Severe Migraines:

• First-line options:
  • Triptans (sumatriptan, rizatriptan, eletriptan)
  • Aspirin-acetaminophen-caffeine combination
  • Triptan + NSAID combination (e.g., sumatriptan 50mg + naproxen)

For Migraines with Prominent Nausea:

• Add an antiemetic to the above treatments 1

Medication Details and Evidence

Triptans

Sumatriptan has strong evidence for efficacy at doses of 25mg, 50mg, and 100mg, with 50mg and 100mg providing greater relief than 25mg, but 100mg not necessarily better than 50mg 2. The maximum daily dose is 200mg in a 24-hour period, and a second dose may be administered if the migraine hasn't resolved after 2 hours 2.

Combination Therapy

The American College of Physicians strongly recommends triptan therapy (such as sumatriptan 50mg) combined with an NSAID (such as naproxen) for breaking migraine attacks, with high-quality evidence supporting this approach 1.

Newer Options

CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant are also available for acute treatment with high-quality evidence supporting their use 1.

Special Populations

Pregnancy

Acetaminophen is the safest acute option during migraine treatment during pregnancy 1.

Hepatic Impairment

For patients with mild to moderate hepatic impairment, the maximum single dose of sumatriptan should not exceed 50mg 2.

Important Considerations and Pitfalls

Medication Overuse Headache

• Limit acute medication use to prevent medication overuse headache:
  • NSAIDs ≤15 days/month
  • Triptans ≤10 days/month 1

Cardiovascular Risk

• Exercise caution with triptan use in patients with cardiovascular risk factors 1

Treatment Response Assessment

• If migraine has not resolved within 2 hours after taking medication or returns after temporary improvement, a second dose may be administered (at least 2 hours after the first dose for triptans) 2

When to Consider Preventive Therapy

Consider preventive therapy if:

• Migraines occur ≥2 times per month
• Attacks are prolonged and disabling
• Quality of life is reduced between attacks 1

Preventive options include propranolol, timolol, amitriptyline, divalproex sodium, sodium valproate, topiramate, and CGRP antagonists 1.

Lifestyle Modifications

All patients should be advised on:

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

The evidence strongly supports a stratified treatment approach based on migraine severity, with NSAIDs and acetaminophen serving as first-line for mild to moderate attacks, and triptans for moderate to severe attacks 1, 3. Over-the-counter medications are particularly important as first-line therapy for most migraineurs due to their efficacy, lower cost, and generally favorable side effect profile 4.