Treatment of Migraine Headaches
For acute migraine treatment, first-line options include NSAIDs (ibuprofen 400-600mg or naproxen sodium 500-550mg) for mild to moderate attacks, while triptans (sumatriptan 50-100mg) are recommended as second-line therapy for moderate to severe attacks. 1
Acute Treatment Algorithm
First-Line Options for Mild to Moderate Attacks
- NSAIDs:
- Ibuprofen 400-600mg
- Naproxen sodium 500-550mg 1
- Acetaminophen (dosing not specified in guidelines)
Second-Line Options for Moderate to Severe Attacks
- Triptans:
Clinical evidence shows that sumatriptan is highly effective, with 50-62% of patients achieving headache relief at 2 hours and 65-79% at 4 hours, compared to only 17-27% with placebo 2. The 100mg dose demonstrates slightly better efficacy than 50mg but with more side effects 2, 3.
Important Timing Considerations
- Triptans are most effective when taken early in an attack while the headache is still mild 1
- Treating during the mild pain phase gives significantly better outcomes than treating established attacks with moderate or severe pain 3
Contraindications and Precautions
Absolute Contraindications for Triptans
- Uncontrolled hypertension
- Cardiovascular disease
- Basilar or hemiplegic migraine
- Concurrent use with MAO-A inhibitors 1
Usage Limitations
- Limit triptan use to no more than 9 days per month
- Limit OTC medications to no more than 14 days per month
- Limit NSAIDs to no more than 15 days per month 1
These limitations are crucial to prevent medication overuse headache, a common complication of frequent acute medication use.
Preventive Treatment
Consider preventive treatment when:
- ≥2 migraine attacks per month with significant disability
- Acute treatments are used more than twice weekly 1
Preventive Options (in order of evidence strength)
- Beta blockers (e.g., propranolol 80-240 mg/day) - high strength of evidence
- CGRP monoclonal antibodies - moderate to high strength of evidence
- Tricyclic antidepressants (e.g., amitriptyline 30-150 mg/day) - moderate strength of evidence, particularly effective for mixed migraine and tension-type headaches
- Anticonvulsants - evidence strength not specified 1
Non-Pharmacological Approaches
These approaches should be integrated with pharmacological treatments:
- Regular aerobic exercise or strength training
- Maintaining a regular sleep schedule
- Adequate hydration
- Identification and avoidance of triggers (alcohol, caffeine, certain foods, stress, fatigue, perfumes, fumes, glare, flickering lights)
- Relaxation techniques or mindfulness
- Neuromodulatory devices
- Biobehavioral therapy
- Acupuncture 1
Rescue Therapy
For severe attacks not responding to first-line or second-line treatments:
- Opioids (e.g., meperidine)
- Butalbital-containing compounds 1
However, these should be used sparingly due to concerns about progression to chronic migraine with frequent use 4.
Common Pitfalls to Avoid
Delayed treatment: Taking medication too late in an attack reduces effectiveness. Encourage early treatment at the first sign of migraine.
Medication overuse: Excessive use of acute medications can lead to medication overuse headache. Strictly adhere to the recommended frequency limitations.
Ignoring contraindications: Triptans should never be used in patients with cardiovascular disease, uncontrolled hypertension, or basilar/hemiplegic migraine due to serious risks.
Failure to consider preventive therapy: Patients with frequent migraines should be evaluated for preventive treatment rather than relying solely on acute medications.
Not monitoring for side effects: Particularly with triptans, monitor for chest symptoms which, though usually benign, could rarely indicate myocardial ischemia 5.
By following this structured approach to migraine management, focusing on appropriate acute treatment based on headache severity and considering preventive options for frequent migraines, most patients can achieve significant improvement in their migraine symptoms and quality of life.