Migraine Treatment
The recommended first-line treatment for acute migraine attacks is nonsteroidal anti-inflammatory drugs (NSAIDs), followed by triptans as second-line therapy when NSAIDs fail or for moderate to severe attacks. 1
Acute Treatment Algorithm
First-Line Therapy
- NSAIDs (most consistent evidence for effectiveness, well-tolerated, cost-effective)
- Ibuprofen 400-600mg
- Naproxen sodium 500-550mg
- Aspirin
- Acetaminophen-aspirin-caffeine combination
- Note: Acetaminophen alone is ineffective for migraine treatment 1
Second-Line Therapy
- Triptans (when NSAIDs fail or for moderate to severe attacks)
- Sumatriptan 50mg orally (optimal balance of efficacy and tolerability) 1, 2
- Sumatriptan 100mg orally (may provide greater effect but with more adverse events) 2, 3
- Sumatriptan 6mg subcutaneously (for severe attacks or significant nausea/vomiting) 1, 4
- Rizatriptan 10mg orally
- Naratriptan or Zolmitriptan (oral formulations)
Important Triptan Contraindications
- Uncontrolled hypertension
- Basilar or hemiplegic migraine
- Cardiovascular disease or risk factors
- Concurrent use with MAO-A inhibitors 1
Route of Administration Considerations
- Consider non-oral routes (subcutaneous, nasal) for patients with significant nausea/vomiting 1
- Subcutaneous administration provides more rapid pain relief than other routes 4
- Taking medication early when pain is mild is more effective than waiting until pain is moderate or severe 4
Adjunctive Therapy
- Antiemetics when nausea is a significant component 1
- Rescue medications for severe attacks unresponsive to first/second-line treatments:
- Opioids (e.g., meperidine)
- Butalbital-containing compounds 1
Preventive Treatment
When to Consider Prevention
- ≥2 migraine attacks per month with significant disability
- Acute treatments used more than twice weekly 1
Preventive Options
Beta blockers
- Propranolol 80-240 mg/day (high strength of evidence) 1
Tricyclic antidepressants
- Amitriptyline 30-150 mg/day (particularly effective for mixed migraine and tension-type headaches) 1
- Monitor for side effects: drowsiness, weight gain, anticholinergic symptoms
Anticonvulsants 1
CGRP monoclonal antibodies (moderate to high strength of evidence) 1
Medication Limitations to Prevent Medication Overuse Headache
- Triptans: No more than 9 days per month 1
- OTC medications: No more than 14 days per month
- NSAIDs: No more than 15 days per month
Dosing Guidelines for Sumatriptan
- If migraine hasn't resolved 2 hours after taking sumatriptan, a second dose may be administered
- Maximum daily dose: 200mg in a 24-hour period 2
- For patients with mild to moderate hepatic impairment, maximum single dose should not exceed 50mg 2
Patient Education and Monitoring
- Track headache frequency, severity, duration, disability, response to treatment, and adverse effects using a headache diary
- Identify and avoid migraine triggers (alcohol, caffeine, certain foods, stress, fatigue, perfumes, fumes, glare, flickering lights) 1
- Regular aerobic exercise, maintaining regular sleep schedule, adequate hydration, and relaxation techniques are recommended non-pharmacological approaches 1
Common Pitfalls and Caveats
- Medication overuse headache - Strictly adhere to recommended medication limitations
- Triptan recurrence - Migraine may recur within 24-48 hours in approximately 40% of patients treated with sumatriptan due to its short half-life (about 2 hours) 5
- Cardiac risk - Cardiac monitoring is recommended for first-time use of subcutaneous sumatriptan in patients with cardiovascular risk factors 1
- Treatment assessment - Evaluate efficacy of preventive treatments after 2-3 months for oral preventives and 3-6 months for CGRP monoclonal antibodies 1
- Progression risk - Chronic migraine is associated with greater burden, more frequent comorbidities, and possibly progressive brain abnormalities, making appropriate treatment essential to prevent progression from episodic to chronic migraine 6