What are the recommended treatments for migraines?

Migraine Treatment Recommendations

NSAIDs are the first-line treatment for mild to moderate migraines, while triptans are recommended for moderate to severe migraines or when NSAIDs fail. 1

Acute Treatment Algorithm

Mild to Moderate Migraines

• First-line: NSAIDs
  • Ibuprofen 400-600mg
  • Naproxen sodium 500-550mg
  • Acetaminophen-aspirin-caffeine combination
  • Take medication early in the headache phase for maximum effectiveness 1
  • Limit use to no more than twice weekly to prevent medication overuse headache 1

Moderate to Severe Migraines

• First-line: Triptans (serotonin 5-HT1B/D agonists)
  • Sumatriptan 50mg orally (recommended starting dose)
  • Sumatriptan 100mg may provide greater efficacy but with more side effects 1, 2
  • Sumatriptan 6mg subcutaneously for severe attacks or significant nausea/vomiting 1
  • Other options: rizatriptan, naratriptan, zolmitriptan 1
  • Maximum daily dose of sumatriptan: 200mg in a 24-hour period 2
  • If migraine hasn't resolved after 2 hours, a second dose may be administered 2

When Triptans Fail or are Contraindicated

• Alternative options:
  • Gepants (CGRP antagonists): ubrogepant or rimegepant 1
  • Ditans (5-HT1F agonists): lasmiditan 1
  • Opioids should only be considered when other medications cannot be used and after addressing abuse risk 1

Special Considerations

Patients with Nausea/Vomiting

• Use non-oral routes of administration:
  • Sumatriptan subcutaneous injection
  • Intranasal DHE
  • Add antiemetic medication to treat nausea 1

Patients with Hepatic Impairment

• For mild to moderate hepatic impairment, maximum single dose of sumatriptan should not exceed 50mg 2

Timing of Medication

• Taking medication early, during the mild pain phase, provides significantly better outcomes than treating established attacks with moderate or severe pain 3

Preventive Treatment

When to Consider Prevention

• ≥2 migraine attacks per month with significant disability
• Acute treatments used more than twice weekly 1

Preventive Options

• First-line: Beta blockers (e.g., propranolol 80-240 mg/day) - high level of evidence 1
• Other options:
  • Tricyclic antidepressants (e.g., amitriptyline 30-150 mg/day) - particularly effective for mixed migraine and tension-type headaches 1
  • Anticonvulsants 1
  • CGRP monoclonal antibodies - moderate to high level of evidence 1

Avoiding Medication Overuse Headache

• Limit NSAIDs to no more than 15 days per month
• Limit triptans to no more than 9 days per month
• Limit OTC medications to no more than 14 days per month
• Limit Ubrelvy to no more than 8 days per month 1

Non-Pharmacological Approaches

• Regular aerobic exercise or strength training
• Maintain regular sleep schedule
• Adequate hydration
• Identify and avoid triggers
• Relaxation techniques or mindfulness
• Neuromodulatory devices, biobehavioral therapy, and acupuncture as adjuncts or standalone treatments when medications are contraindicated 1

Efficacy and Monitoring

• Assess treatment efficacy after 2-3 months for oral preventives and 3-6 months for CGRP monoclonal antibodies
• Evaluate patients for high-risk factors including anxiety, depression, and medication overuse 1

Important Cautions

• Triptans are contraindicated in patients with uncontrolled hypertension, basilar or hemiplegic migraine, and cardiovascular disease 1
• Adverse events with sumatriptan are generally transient and mild, with a clear dose-response relationship (25mg to 100mg) 3
• Subcutaneous administration provides more rapid pain relief than other routes but has higher rates of adverse events 4