What are the treatment options for migraines?

Migraine Treatment Options

The most effective approach for treating moderate to severe migraine attacks is a combination of a triptan plus NSAID, which should be started as early as possible after migraine onset. 1

First-Line Treatments

Mild to Moderate Attacks

• NSAIDs are the first choice for mild to moderate attacks 1:

  • Ibuprofen
  • Aspirin
  • Naproxen
  • Diclofenac

• Acetaminophen is effective for mild attacks, especially when combined with aspirin and caffeine 1

  • First-line during pregnancy (650-1000 mg every 4-6 hours, maximum 4g/day)

Moderate to Severe Attacks

• Triptans (second-line therapy) 1, 2:

  • Sumatriptan (oral, nasal spray, or injection)
  • Rizatriptan
  • Zolmitriptan
  • Eletriptan
  • Almotriptan
  • Frovatriptan
  • Naratriptan

• Key triptan considerations 3, 4:

  • Contraindicated in coronary artery disease, Prinzmetal's variant angina, uncontrolled hypertension, history of stroke/TIA, and Wolff-Parkinson-White syndrome
  • May cause chest/jaw/neck tightness (usually non-cardiac)
  • Risk of serotonin syndrome when combined with SSRIs/SNRIs
  • Limit to ≤10 days/month to prevent medication overuse headache

Third-Line Treatments

• CGRP antagonists (gepants) for patients who don't respond to or cannot tolerate triptans + NSAIDs 1

  • Ubrogepant (50-100 mg at onset, maximum 200 mg in 24 hours)

• Ditans (lasmiditan) should only be considered after failure of all other treatments 1

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

Treatment Algorithm

1. For mild to moderate attacks:

   • Start with oral NSAIDs or acetaminophen
   • If insufficient relief, add a triptan

2. For moderate to severe attacks:

   • Start with triptan + NSAID combination immediately
   • Use early in the attack for best results
   • Consider non-oral triptans for patients with severe nausea/vomiting

3. For refractory attacks:

   • Try gepants (CGRP antagonists)
   • Consider ditans (lasmiditan) as last resort
   • DHE may be an option

Preventive Treatment Options

For patients with frequent migraines, consider preventive treatment with:

• Beta-blockers 1:

  • Propranolol (80-240 mg/day)
  • Timolol (20-30 mg/day)
  • Avoid in patients with asthma, heart failure, Raynaud's disease, AV block, or depression

• Antidepressants 1:

  • Amitriptyline (30-150 mg/day)

• Anticonvulsants 1:

  • Divalproex sodium (500-1500 mg/day) - contraindicated in pregnancy
  • Topiramate (100 mg/day)

Important Cautions and Contraindications

• Avoid opioids and butalbital due to risk of dependence and medication overuse headache 1

• Medication overuse headache prevention 1:

  • Limit NSAIDs to ≤15 days/month
  • Limit triptans to ≤10 days/month

• Triptan contraindications 3, 4:

  • Coronary artery disease
  • Uncontrolled hypertension
  • History of stroke or TIA
  • Wolff-Parkinson-White syndrome
  • Within 24 hours of ergot derivatives

• Valproate is contraindicated during pregnancy due to teratogenicity 1

Lifestyle Modifications

• Track triggers and symptoms with a headache diary 1
• Maintain regular sleep schedule, consistent meal times, and adequate hydration 1
• Practice stress management techniques 1
• Regular exercise 1

By following this evidence-based approach to migraine treatment, patients can achieve better control of their migraine attacks and improved quality of life.