What are the treatment options for migraine?

Treatment Options for Migraine

The first-line treatments for migraine include preventive medications such as anticonvulsants (topiramate), beta-blockers (propranolol), and antidepressants (amitriptyline), while acute treatments include NSAIDs, triptans, and combination therapy depending on severity. 1, 2

Acute Treatment Options

Mild to Moderate Attacks

• First-line: Simple analgesics
  • Paracetamol (acetaminophen): 650-1000 mg every 4-6 hours (max 4g/day) 2, 3
  • NSAIDs: Indomethacin may be preferred in certain patients due to its effect on reducing intracranial pressure 2

Moderate to Severe Attacks

• First-line: Triptans (with or without NSAIDs) 2, 4, 3

  • Sumatriptan: Available in multiple formulations
    • Oral: 25mg, 50mg, or 100mg (50mg and 100mg show better efficacy than 25mg) 4
    • Subcutaneous injection (6mg): Provides fastest relief with highest Cmax of 71 ng/mL 4
  • Start treatment as early as possible during attack onset 2
  • Contraindicated in patients with:
    • Coronary artery disease
    • Prinzmetal's variant angina
    • Wolff-Parkinson-White syndrome
    • History of stroke/TIA
    • Uncontrolled hypertension 4

• Second-line: When triptans are contraindicated or ineffective 2, 3

  • Antiemetics
  • Ergot alkaloids
  • CGRP antagonists (gepants)
  • Ditans (lasmiditan)

Important: Avoid opioids and butalbital-containing medications for migraine treatment unless other options have failed 3

Preventive Treatment Options

Indications for Preventive Therapy

• Frequent headaches (typically 4+ per month)
• Debilitating headaches despite adequate acute treatment
• Contraindications to acute treatments
• Using acute treatments more frequently than recommended
• Patient preference 1, 5

First-line Preventive Medications

1. Beta-blockers:

   • Propranolol: 80-240 mg/day
   • Timolol: 20-30 mg/day 2

2. Anticonvulsants:

   • Topiramate: Start at 25mg, escalate weekly to target dose of 100 mg/day
   • Divalproex sodium: 500-1500 mg/day
   • Sodium valproate: 800-1500 mg/day 2

     Caution: Valproate is contraindicated during pregnancy due to teratogenicity 2

3. Tricyclic antidepressants:

   • Amitriptyline: 30-150 mg/day 2

4. CGRP receptor antagonists:

   • Consider for patients who fail other preventive treatments 5
   • Use may be limited by cost and insurance coverage

Second-line Options

If first-line treatments are not tolerated or ineffective, consider:

• ACE inhibitor (lisinopril)
• ARBs (candesartan or telmisartan)
• SSRIs (fluoxetine) 1
• OnabotulinumtoxinA (Botox) for chronic migraine 5

Non-pharmacological Approaches

Lifestyle Modifications

• Identify and avoid migraine triggers (alcohol, excessive caffeine, sleep deprivation, stress) 5, 6
• Maintain regular sleep schedule and adequate hydration 2
• Regular physical activity and weight management for overweight/obese patients 2, 6
• Stress management techniques (yoga, cognitive-behavioral therapy, mindfulness) 2

Monitoring Tools

• Use a headache diary to track:
  • Frequency and severity of attacks
  • Identified triggers
  • Response to treatments
  • Medication use (to identify potential overuse) 1, 2

Important Clinical Considerations

• Medication overuse headache: Can develop with use of acute medications (triptans, ergotamines, opioids) for ≥10 days/month or simple analgesics for ≥15 days/month 4

• Treatment duration: Allow preventive medications 2-3 months to achieve maximum efficacy before switching 1, 2

• Serotonin syndrome risk: Use caution when combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors 4

• Gradual titration: Start preventive medications at low doses and gradually increase to effective dose or until side effects occur 1

• Pregnancy considerations: Discuss medication risks during pregnancy and breastfeeding; avoid valproate 2

By following this structured approach to migraine management, focusing on both acute and preventive strategies, patients can experience reduced headache frequency, improved response to acute treatments, and better quality of life.