What are the treatment options for migraines?

Treatment Options for Migraines

For acute migraine treatment, start with NSAIDs or acetaminophen, then add a triptan if needed, and consider newer agents like gepants or ditans only when first-line treatments fail. 1

First-Line Treatment for Acute Migraine

Mild to Moderate Migraine

• NSAIDs: First choice for mild to moderate attacks 1
  • Options: ibuprofen (400-800mg), aspirin (650-1000mg), naproxen, diclofenac
  • Maximum: Be careful not to exceed 15 days/month to avoid medication overuse headache 1, 2
• Acetaminophen: 650-1000mg every 4-6 hours (maximum 4g/day) 2
  • Particularly appropriate for pregnant women or those with NSAID contraindications 2
• Combination analgesics: Acetaminophen + aspirin + caffeine can be effective 1

Moderate to Severe Migraine

• Triptan + NSAID combination: This is the most effective approach for moderate to severe attacks 1
  • Begin treatment as soon as possible after migraine onset 1
  • Options include any triptan (sumatriptan, rizatriptan, zolmitriptan, etc.) combined with an NSAID
  • Triptans provide pain freedom at 2 hours in 42-76% of patients 3

Important Considerations for Acute Treatment

• Treat early in the attack for best results 1
• For patients with severe nausea/vomiting, consider non-oral triptans and antiemetics 1
• Avoid opioids and butalbital for migraine treatment 1
• Monitor for medication overuse headache (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1

Second and Third-Line Treatment Options

When First-Line Treatments Fail

• CGRP antagonists (gepants): Consider rimegepant, ubrogepant, or zavegepant for patients who don't respond to or cannot tolerate triptans + NSAIDs 1

  • Dosage: Ubrogepant 50-100mg at onset (maximum 200mg/24 hours) 2

• Ditan (lasmiditan): Consider only after failure of all other treatments 1

• Dihydroergotamine (DHE): May be an option for those who don't respond to triptans + NSAIDs 1

Special Considerations

• Cardiovascular risk: Triptans are contraindicated in patients with:

  • Coronary artery disease
  • Prinzmetal's variant angina
  • Uncontrolled hypertension
  • History of stroke or TIA
  • Wolff-Parkinson-White syndrome 4, 5

• Serotonin syndrome risk: Use caution when combining triptans with SSRIs or SNRIs 4, 5

Preventive Treatment for Frequent Migraines

When acute treatments are needed frequently or don't provide adequate relief, consider preventive medications 1:

• Beta-blockers: Propranolol (80-240mg/day) or timolol (20-30mg/day) 2
• Antidepressants: Amitriptyline (30-150mg/day) 2
• Anticonvulsants: Topiramate (100mg/day) or divalproex sodium (500-1500mg/day) 2
  • Note: Valproate is contraindicated during pregnancy due to teratogenicity 2

Lifestyle Modifications and Non-Pharmacological Approaches

All patients should be counseled on these important lifestyle modifications 1, 2:

• Stay well hydrated
• Maintain regular meals
• Ensure sufficient and consistent sleep
• Engage in regular physical activity (preferably moderate to intense aerobic exercise)
• Manage stress with relaxation techniques or mindfulness practices
• Pursue weight loss if overweight or obese
• Use a headache diary to identify and avoid triggers

Treatment Algorithm

1. Initial approach: Start with NSAIDs or acetaminophen for mild to moderate attacks
2. If inadequate response: Add a triptan (use combination therapy)
3. If still inadequate: Consider CGRP antagonists or DHE
4. Last resort: Consider lasmiditan if all other treatments fail
5. For prevention: Add preventive medication if attacks are frequent (>4/month) or acute treatments are inadequate

Common Pitfalls to Avoid

• Medication overuse: Limit acute medications to prevent medication overuse headache
• Delayed treatment: Counsel patients to treat early in the attack
• Inadequate dosing: Ensure patients are using appropriate doses before switching medications
• Ignoring non-pharmacological approaches: Lifestyle modifications are an essential component of treatment
• Using opioids: These should be avoided due to risk of dependence and medication overuse headache 1