Current Guidelines for Migraine Treatment
The most current guidelines for migraine treatment recommend NSAIDs as first-line therapy for acute attacks, followed by triptans if NSAIDs fail, while preventive treatment should be considered for patients with frequent or disabling migraines, with CGRP antagonists like erenumab being strongly recommended for prevention. 1, 2
Acute Treatment
First-Line Treatment
- NSAIDs are recommended as first-line treatment for most patients with migraine
- Ibuprofen (400-600mg)
- Naproxen sodium (500-550mg)
- Aspirin (900-1000mg)
- Acetaminophen-aspirin-caffeine combination 2
Second-Line Treatment
- Triptans for patients whose migraine attacks do not respond to NSAIDs:
Newer Acute Treatments
- CGRP receptor antagonists:
- Rimegepant or ubrogepant are suggested for short-term treatment of migraine 1
Special Considerations
- Use non-oral routes of administration when nausea/vomiting are significant
- Add antiemetics for nausea
- Limit use of acute medications to prevent medication overuse headache:
- Triptans: no more than 9 days per month
- NSAIDs: no more than 15 days per month 2
Preventive Treatment
Strong Recommendations
- CGRP monoclonal antibodies:
Moderate Recommendations
- Intravenous eptinezumab is suggested for prevention of episodic or chronic migraine 1
- Topiramate is suggested for prevention of episodic and chronic migraine 1
- Beta blockers:
- Other medications with weak recommendations:
- Lisinopril for episodic migraine
- Oral magnesium for migraine prevention
- Valproate for episodic migraine
- Memantine for episodic migraine
- Atogepant for episodic migraine
- OnabotulinumtoxinA for chronic migraine 1
Not Recommended
- Against using:
- Gabapentin for prevention of episodic migraine
- AbobotulinumtoxinA or onabotulinumtoxinA for prevention of episodic migraine
- Galcanezumab for prevention of chronic cluster headache 1
Indications for Preventive Treatment
- ≥2 migraine attacks per month with disability for ≥3 days per month
- Use of rescue medication more than twice a week
- Failure of or contraindications to acute treatments
- Presence of uncommon migraine conditions (e.g., hemiplegic migraine) 1, 2
Treatment Approach
- Stratified care (selecting initial treatment based on headache severity) provides better outcomes than step care approaches 4
- For mild to moderate attacks: Start with NSAIDs
- For severe attacks or those not responding to NSAIDs: Use triptans
- For refractory attacks: Consider combination therapy (NSAID + triptan) or rescue medications 5, 6
Special Populations
Pediatric and Adolescent Patients
- Ibuprofen is recommended to treat pain in children/adolescents
- In adolescents, consider sumatriptan/naproxen, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan 1
- Discuss evidence for amitriptyline combined with cognitive behavioral therapy, topiramate, and propranolol for prevention 1
Common Pitfalls to Avoid
- Medication overuse: Limiting acute medication use is crucial to prevent medication overuse headache
- Delayed treatment: Treating attacks early improves outcomes
- Inadequate dosing: Using subtherapeutic doses reduces effectiveness
- Ignoring contraindications: Triptans should not be used in patients with uncontrolled hypertension, cardiovascular disease, or basilar/hemiplegic migraine 2
- Overlooking non-pharmacological approaches: Regular sleep schedule, hydration, trigger avoidance, and stress management are important components of migraine management
By following these evidence-based guidelines and avoiding common pitfalls, clinicians can optimize migraine treatment outcomes and significantly improve patients' quality of life.