What are the recommended treatments for migraines?

Migraine Treatment Recommendations

For acute migraine treatment, NSAIDs (ibuprofen 400-600mg or naproxen 500-550mg) and triptans (sumatriptan 50mg) are first-line options, while preventive therapy should be initiated with beta-blockers (propranolol 80-240mg/day) or CGRP antagonists for patients with frequent migraines. 1

Acute Treatment Options

First-Line Treatments

• NSAIDs:

  • Ibuprofen 400-600mg 1
  • Naproxen sodium 500-550mg 1
  • Take at onset of headache with food to minimize GI side effects
  • Limit use to no more than 15 days per month to prevent medication overuse headache

• Acetaminophen:

  • 1000mg 1
  • Avoid in patients with liver disease
  • Can be combined with aspirin and caffeine for mild to moderate headaches (avoid in patients with peptic ulcer disease or bleeding disorders)

Second-Line Treatments

• Triptans:

  • Sumatriptan 50mg orally is the recommended starting dose 1, 2
  • 50mg dose provides similar efficacy to 100mg with fewer adverse effects 2, 3
  • Maximum daily dose: 200mg in a 24-hour period 2
  • If first dose doesn't work, a second dose may be taken after 2 hours 2
  • Limit use to no more than 9 days per month to prevent medication overuse headache 1
  • Contraindicated in patients with cardiovascular disease 4

• CGRP Antagonists:

  • Rimegepant or ubrogepant 1
  • Limit ubrogepant to no more than 8 days per month 1

Other Acute Options

• Greater occipital nerve block for short-term treatment 1
• Normobaric oxygen therapy 1
• For severe attacks or significant nausea/vomiting: Sumatriptan 6mg subcutaneously (most effective route but with higher incidence of adverse events) 1, 5

Preventive Treatment

When to Consider Prevention

• Frequent migraines (especially approaching 15 headache days per month) 6
• Significant disability despite acute treatment
• Risk of progression from episodic to chronic migraine 6
• Medication overuse or contraindication to acute treatments

First-Line Preventive Options

• Beta-blockers:

  • Propranolol (80-240 mg/day) 1
  • Timolol (20-30 mg/day) 1
  • Particularly effective for frequent and disabling headaches

• Tricyclic Antidepressants:

  • Amitriptyline (30-150 mg/day) 1
  • Start low (10mg) and increase gradually
  • Particularly effective for mixed migraine and tension-type headaches
  • Use with caution in elderly patients and those with cardiac comorbidities due to anticholinergic effects

• CGRP Monoclonal Antibodies:

  • Erenumab, fremanezumab, galcanezumab 1
  • Strong option for preventive therapy in patients with frequent migraines
  • Galcanezumab specifically recommended for episodic cluster headache prevention

• Anticonvulsants:

  • Divalproex sodium (500-1500 mg/day) 1
  • Consider for refractory cases
  • Requires monitoring for weight gain, hair loss, and tremor

Non-Pharmacological Approaches

• Lifestyle Modifications:

  • Regular sleep schedule 1
  • Adequate hydration 1
  • Identification and avoidance of triggers 1

• Physical Interventions:

  • Regular aerobic exercise or progressive strength training 1
  • Physical therapy for tension-type, migraine, or cervicogenic headache 1
  • Relaxation techniques or mindfulness practice 1
  • Noninvasive vagus nerve stimulation for episodic cluster headache 1

Treatment Pearls and Pitfalls

• Early Treatment: Treating early during mild pain phase provides significantly better outcomes than waiting until pain is moderate or severe 5

• Medication Overuse: Strictly limit acute medications to prevent medication overuse headache:

  • Triptans: No more than 9 days per month 1
  • NSAIDs: No more than 15 days per month 1
  • OTC medications: No more than 14 days per month 1

• Headache Recurrence: Headaches may recur in 21-57% of patients after sumatriptan treatment, but most respond to a second dose 4

• Monitoring: Schedule follow-up in 4-6 weeks to assess treatment effectiveness 1

• Preventive Medication Expectations: Allow 2-3 months for full benefit of preventive medications to develop 1

• Special Populations:

  • For patients with hepatic impairment, maximum single dose of sumatriptan should not exceed 50mg 2
  • Screen for anxiety and depression, especially in patients with frequent headaches 1