What are the treatment options for migraines?

Treatment Options for Migraines

For most migraine patients, a stepped approach starting with NSAIDs as first-line treatment, followed by triptans as second-line treatment for those who don't respond to NSAIDs, is the most effective strategy for managing acute migraine attacks while minimizing risks of medication overuse headache.

First-Line Treatment Options for Acute Migraine

NSAIDs and Simple Analgesics

• First-line treatment for mild to moderate migraines includes:
  • Ibuprofen (400-600mg)
  • Naproxen sodium (500-550mg)
  • Aspirin
  • Acetaminophen-aspirin-caffeine combination 1, 2
• Note that acetaminophen alone is ineffective for migraine 1
• These medications should be limited to no more than 14-15 days per month to prevent medication overuse headache 2

Second-Line Treatment Options

Migraine-Specific Medications (Triptans)

• Indicated when NSAIDs fail or for moderate to severe migraine attacks 1, 2

• Recommended options include:

  • Sumatriptan: 6mg subcutaneously (most rapid relief) or 50mg orally
  • Rizatriptan: 10mg orally
  • Naratriptan: oral formulation
  • Zolmitriptan: oral formulation 1, 2, 3

• Important contraindications for triptans:

  • Uncontrolled hypertension
  • Basilar or hemiplegic migraine
  • Cardiovascular disease or risk factors
  • Concurrent use with MAO-A inhibitors 1, 2, 4

• Safety considerations:

  • Limit triptan use to no more than 9 days per month 2
  • Monitor for serotonin syndrome when used with SSRIs or SNRIs 4
  • Be aware of potential cardiovascular events (rare but serious) 4

Alternative Second-Line Options

• Dihydroergotamine (DHE) intranasal spray has good evidence for efficacy 1, 2
• Butorphanol nasal spray may be considered in specific cases 1

Route of Administration Considerations

• For patients with significant nausea or vomiting:
  • Use non-oral routes of administration 1, 2
  • Subcutaneous sumatriptan (6mg) offers most rapid relief 2
  • Intranasal formulations are also effective options 2

Rescue Medications

• When first and second-line treatments fail, consider:
  • Opioids (with caution regarding risk of dependence)
  • Butalbital-containing compounds 1, 2
• These should be limited to situations where other options have failed and risk of abuse has been addressed 1, 5

Preventive Treatment

Consider preventive treatment when:

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

Preventive medication options:

• Beta blockers (propranolol 80-240 mg/day)
• Tricyclic antidepressants (amitriptyline 30-150 mg/day)
• Anticonvulsants
• CGRP monoclonal antibodies 2

Non-Pharmacological Approaches

• Regular aerobic exercise or strength training
• Maintaining regular sleep schedule
• Adequate hydration
• Identification and avoidance of triggers
• Relaxation techniques or mindfulness 2

Important Clinical Pearls

1. Avoid medication overuse: Limit acute treatments to prevent medication-overuse headache:

   • Triptans: no more than 9 days/month
   • NSAIDs: no more than 15 days/month 1, 2

2. Monitor for rebound headaches: Associated with withdrawal of analgesics or abortive migraine medications, particularly with opiates, triptans, ergotamine, and medications containing caffeine, isometheptene, or butalbital 1

3. Patient education: Encourage patients to track headache frequency, severity, duration, disability, response to treatment, and adverse effects using a headache diary 1

4. Identify triggers: Help patients recognize factors that may trigger migraines (alcohol, caffeine, certain foods, stress, fatigue, perfumes, fumes, glare, flickering lights) 1