What are the recommended treatments for migraines?

Migraine Treatment Recommendations

NSAIDs should be used as first-line therapy for acute migraine attacks, followed by triptans if NSAIDs fail, with combination therapy recommended for patients with inadequate response to monotherapy. 1

Acute Treatment Algorithm

First-Line Treatment

• NSAIDs:
  • Ibuprofen 400-600mg
  • Naproxen sodium 500-550mg 1
  • Begin at onset of migraine for best results

Second-Line Treatment

• Triptans (if NSAIDs fail):
  • Sumatriptan 50mg orally (recommended starting dose)
  • Can increase to 100mg if 50mg ineffective (100mg may provide greater effect but with increased adverse events) 2
  • For severe attacks or significant nausea/vomiting: Sumatriptan 6mg subcutaneously 1
  • Other options: Eletriptan, frovatriptan, rizatriptan, zolmitriptan 1

Combination Therapy

• Triptan + NSAID for inadequate response to monotherapy 1
• This approach provides superior relief compared to either medication alone

Rescue Medications

• For severe attacks unresponsive to first/second-line treatments:
  • Opioids (e.g., meperidine)
  • Butalbital-containing compounds 1
  • Antiemetics (even if vomiting is not present) 1

Important Dosing Considerations

• Sumatriptan dosing:

  • If migraine not resolved after 2 hours, a second dose may be administered
  • Maximum daily dose: 200mg in 24-hour period 2
  • For patients with hepatic impairment: Maximum single dose should not exceed 50mg 2
  • Subcutaneous administration provides more rapid relief than oral route 3

• Medication limitations to prevent medication overuse headache:

  • Triptans: No more than 9 days per month
  • OTC medications: No more than 14 days per month
  • NSAIDs: No more than 15 days per month 1

Preventive Treatment

Indications for Prevention

• ≥2 attacks per month with significant disability
• Failure of or contraindication to acute treatments
• Use of abortive medications more than twice weekly
• Uncommon migraine conditions 1

First-Line Preventive Options

• CGRP monoclonal antibodies (strongly recommended):
  • Erenumab, fremanezumab, galcanezumab 1

Additional Preventive Options

• Topiramate
• Beta blockers (e.g., propranolol)
• Tricyclic antidepressants (e.g., amitriptyline) 1

Special Populations

Pediatric and Adolescent Management

• First-line: Ibuprofen for pain relief
• Second-line options:
  • Sumatriptan/naproxen
  • Zolmitriptan nasal
  • Sumatriptan nasal
  • Rizatriptan ODT
  • Almotriptan 1

Contraindications for Triptans

• Uncontrolled hypertension
• Cardiovascular disease
• Basilar or hemiplegic migraine 1

Non-Pharmacological Management

• Regular aerobic exercise or strength training
• Maintaining 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

Clinical Pearls and Pitfalls

• Early treatment is more effective: Taking medication during the mild pain phase provides better outcomes than treating established attacks with moderate/severe pain 4
• Monitor for medication overuse: Headache diaries can help track frequency, severity, duration, disability, response to treatment, and adverse effects 1
• Consider route of administration: Subcutaneous administration is most effective (59% pain-free at 2 hours vs. 15% with placebo) but has more adverse events than oral administration 3
• Adverse events: Generally mild to moderate and transient, with higher incidence at higher doses and with subcutaneous administration 3
• Economic impact: Despite higher acquisition costs, sumatriptan treatment may result in overall cost savings through reduced workplace productivity losses 5

By following this evidence-based approach to migraine management, clinicians can effectively address both acute attacks and implement preventive strategies to reduce migraine frequency and improve patients' quality of life.