What is the recommended initial management for migraine?

Initial Management of Migraine

The recommended initial management for migraine is to use NSAIDs (ibuprofen 400-600 mg, naproxen sodium 500-550 mg, or aspirin) as first-line medication for mild to moderate attacks, with triptans as second-line therapy for moderate to severe attacks or when NSAIDs fail. 1

Assessment and Diagnosis

Before initiating treatment, screen for red flags that may indicate secondary headache:

• Thunderclap headache (subarachnoid hemorrhage)
• Atypical aura (TIA, stroke, epilepsy)
• Progressive headache (intracranial lesion)
• Headache onset after age 50
• Focal neurological symptoms
• Unexplained fever or neck stiffness
• Headache aggravated by postures that raise intracranial pressure 2

Acute Treatment Algorithm

First-Line Treatment (Mild to Moderate Attacks)

• NSAIDs:
  • Ibuprofen 400-600 mg
  • Naproxen sodium 500-550 mg
  • Aspirin 800-1000 mg 1, 2
  • Diclofenac potassium

Second-Line Treatment (Moderate to Severe Attacks or First-Line Failure)

• Triptans:
  • Sumatriptan: 50 mg orally (can increase to 100 mg if needed, max 200 mg/24 hours) 3
  • Rizatriptan: 10 mg orally for adults and adolescents ≥40kg 1
  • Consider subcutaneous sumatriptan 6 mg for severe attacks or significant nausea/vomiting 1

Third-Line Treatment (When Triptans Fail or Are Contraindicated)

• Ditans (lasmiditan)
• Gepants (ubrogepant, rimegepant) 1, 2

Key Treatment Principles

1. Early intervention: Take medication early in the headache phase (not during aura) when pain is still mild 1

2. Combination approach: Consider combining triptans with fast-acting NSAIDs to prevent recurrence 2

3. Adjunct medications: For nausea/vomiting, add prokinetic antiemetics:

   • Domperidone
   • Metoclopramide 2

4. Avoid medication overuse: Limit acute medications to prevent medication overuse headache:

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

5. Medications to avoid:

   • Oral ergot alkaloids (poorly effective, potentially toxic)
   • Opioids and barbiturates (questionable efficacy, risk of dependency) 2

When to Consider Preventive Treatment

Initiate preventive therapy when:

• Migraine attacks occur ≥2 days/month with significant disability
• Acute treatments fail or are contraindicated
• Acute medications are used more than twice per week
• Patient has uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 2, 1

Evidence Quality and Treatment Strategy

The stratified care approach (selecting initial treatment based on attack severity) has shown superior outcomes compared to step care approaches (starting with simple analgesics and escalating as needed) 4. A randomized controlled trial demonstrated that stratified care provided significantly better headache response and reduced disability time compared to step care strategies 4.

Common Pitfalls to Avoid

1. Delayed treatment: Waiting too long to take medication reduces effectiveness 1

2. Medication overuse: Using acute treatments too frequently can lead to medication overuse headache 2

3. Inadequate dosing: Underdosing reduces effectiveness (e.g., sumatriptan 50 mg is often more effective than 25 mg) 3

4. Failure to provide rescue medication: Patients with severe attacks should have a rescue plan to avoid emergency department visits 2

5. Ignoring non-pharmacological approaches: Regular sleep, hydration, trigger avoidance, and stress management are important adjuncts to medication 1

By following this evidence-based approach to initial migraine management, clinicians can help patients achieve better control of their migraine attacks and improve quality of life.