Current Treatment Options for Migraines
The most effective approach to migraine management includes both pharmacological and non-pharmacological interventions, with treatment selection based on migraine severity, frequency, and individual patient factors as recommended by the American Academy of Neurology. 1
Acute Treatment Options
First-Line Treatments
For mild to moderate migraines:
- NSAIDs (ibuprofen, naproxen)
- Acetaminophen
- Combination of NSAID + acetaminophen 1
For moderate to severe migraines:
- Triptans (sumatriptan, rizatriptan, zolmitriptan, etc.)
- Combination of triptan + NSAID (provides superior relief compared to either medication alone) 1
Second-Line and Alternative Options
CGRP antagonists (gepants):
- Rimegepant, ubrogepant, zavegepant
- Particularly useful for patients with contraindications to triptans 1
Ditans:
- Lasmiditan
- Note: Patients should not drive or operate machinery for at least 8 hours after taking lasmiditan 1
Alternative delivery systems for patients with significant nausea/vomiting:
- Intranasal triptans (sumatriptan, zolmitriptan)
- Subcutaneous sumatriptan (fastest onset of action)
- Orally disintegrating tablets (rizatriptan, zolmitriptan) 2
Important Considerations for Acute Treatment
- Begin treatment early in the attack to prevent central sensitization 2
- Limit acute medication use to prevent medication overuse headache:
- NSAIDs: ≤15 days/month
- Triptans: ≤10 days/month 1
- Monitor for triptan-associated side effects including chest/throat tightness, paresthesia, flushing, dizziness, and somnolence 3
- Avoid triptans in patients with uncontrolled hypertension, cardiovascular disease, or history of stroke 3
Preventive Treatment
When to Consider Prevention
Preventive therapy should be considered when:
- Migraines occur ≥2 times per month
- Attacks are prolonged and disabling
- Quality of life is reduced between attacks
- Target: 50% reduction in attack frequency 1
First-Line Preventive Medications
| Medication | Daily Dosage |
|---|---|
| Propranolol | 80-240 mg |
| Timolol | 20-30 mg |
| Amitriptyline | 30-150 mg |
| Divalproex sodium | 500-1500 mg |
| Topiramate | 100 mg |
CGRP Monoclonal Antibodies
- Erenumab, fremanezumab, galcanezumab
- Consider after inadequate response to traditional preventives
- Administered as monthly or quarterly injections 1
CGRP Antagonists for Prevention
- Rimegepant, ubrogepant
- Newer options with different mechanism than traditional preventives 1
Non-Pharmacological Approaches
Evidence-Based Lifestyle Modifications
- Regular physical exercise (40 minutes, three times weekly)
- Regular sleep schedule
- Consistent meal times and adequate hydration
- Stress management techniques 1
Complementary Approaches
- Cognitive behavioral therapy
- Relaxation techniques (abdominal breathing, progressive muscle relaxation)
- Supplements:
- Magnesium (400-600mg daily)
- Riboflavin (400mg daily)
- Coenzyme Q10
- Feverfew 1
Special Populations
Pregnancy
- Acetaminophen is the safest acute option during pregnancy 1
- Avoid valproate derivatives in women of childbearing potential due to teratogenic risk 1
Patients with Comorbidities
- Cardiovascular disease: Use caution with triptans 1
- Diabetes: Monitor blood glucose more frequently when initiating new medications 1
- Obesity: Consider topiramate which may assist with weight loss 1
Treatment Pitfalls to Avoid
- Delaying treatment during an acute attack
- Overusing acute medications (leading to medication overuse headache)
- Failing to address lifestyle factors and triggers
- Not considering preventive therapy when indicated
- Using triptans in patients with contraindications 1, 3
Remember that migraine is a neurological disorder with a biological basis requiring comprehensive management. Treatment should be adjusted based on response, with adequate trial periods (6-8 weeks at therapeutic doses) before determining effectiveness of preventive medications.