What is the primary treatment for migraines?

Primary Treatment for Migraines

The primary treatment for acute migraine episodes consists of NSAIDs (such as ibuprofen or naproxen), acetaminophen, or a combination of NSAID + acetaminophen, with triptan therapy (such as sumatriptan) combined with an NSAID recommended for breaking more severe migraine attacks. 1

Acute Treatment Algorithm

1. First-line options for mild to moderate migraines:

   • NSAIDs (ibuprofen, naproxen)
   • Acetaminophen
   • Combination of NSAID + acetaminophen

2. First-line options for moderate to severe migraines:

   • Triptan (sumatriptan 25-100mg) + NSAID combination
   • Note: 50mg dose of sumatriptan may be optimal as 100mg doses may not provide additional benefit but could increase adverse effects 2

3. For patients with prominent nausea:

   • Add an antiemetic medication to the above regimens 1

4. Third-line options (after triptan failure):

   • CGRP antagonists (gepants) such as rimegepant or ubrogepant
   • Ditans such as lasmiditan (with caution about driving restrictions) 1

Important Administration Guidelines

• If migraine has not resolved within 2 hours after taking sumatriptan or returns after improvement, a second dose may be administered (at least 2 hours after first dose)
• Maximum daily dose of sumatriptan is 200mg in a 24-hour period 2
• Take medication early in the migraine attack for optimal effectiveness 3
• Limit acute medication use to prevent medication overuse headache: NSAIDs ≤15 days/month and triptans ≤10 days/month 1

Preventive Treatment

Preventive therapy should be considered when:

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

First-line preventive options include:

• Beta-blockers (propranolol 80-240 mg/day, timolol 20-30 mg/day)
• Tricyclic antidepressants (amitriptyline 30-150 mg/day)
• Anticonvulsants (topiramate 100 mg/day, divalproex sodium 500-1500 mg/day) 1

For patients with inadequate response to traditional preventives, CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) should be considered 1.

Non-Pharmacological Approaches

These approaches should complement pharmacological treatment:

• Regular sleep schedule
• Consistent meal times
• Adequate hydration
• Regular physical exercise (40 minutes three times weekly) 4
• Stress management techniques
• Cognitive behavioral therapy
• Relaxation techniques (abdominal breathing exercises, progressive muscle relaxation) 4, 1

Special Considerations and Cautions

• Cardiovascular risk: Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's variant angina, Wolff-Parkinson-White syndrome, or other cardiac conduction disorders 2
• Hepatic impairment: Maximum single dose of sumatriptan should not exceed 50mg in patients with mild to moderate hepatic impairment 2
• Pregnancy: Acetaminophen is the safest acute option 1
• Medication overuse: Can lead to exacerbation of headaches; may require detoxification and withdrawal of overused medications 2
• Serotonin syndrome: Risk increases with concomitant use of SSRIs, SNRIs, TCAs, and MAO inhibitors 2

Monitoring and Follow-up

• Use a headache diary to track frequency, duration, intensity, triggers, and medication response 1
• Allow 6-8 weeks at therapeutic dose to assess effectiveness of preventive medications 1
• Target at least 50% reduction in attack frequency with preventive therapy 1

Patient education is essential - migraine is a neurological disorder with biological basis that often requires both pharmacological and non-pharmacological approaches for optimal management 4.