What are the treatment options for migraine?

Treatment Options for Migraine

The most effective approach for migraine management includes both acute and preventive treatments, with first-line acute therapy being triptans combined with NSAIDs for moderate to severe attacks, and first-line preventive options including propranolol, metoprolol, topiramate, and divalproex sodium for patients with frequent or debilitating episodes. 1, 2

Acute Migraine Treatment

First-line Options:

• Mild to Moderate Attacks:

  • Acetaminophen (paracetamol): 650-1000 mg every 4-6 hours (maximum 4g/day) 1
  • NSAIDs (e.g., ibuprofen, naproxen)

• Moderate to Severe Attacks:

  • Triptan + NSAID combination (most effective approach) 1
  • Sumatriptan: Available in multiple formulations
    • Oral: 25mg, 50mg, or 100mg (50mg and 100mg show better efficacy than 25mg) 3
    • Subcutaneous: 6mg (provides fastest relief) 1, 3

Second-line Options:

• CGRP antagonists (gepants) for patients who don't respond to or cannot tolerate triptans 1, 2
• Ditans (lasmiditan) - effective but may have limiting side effects 2
• Antiemetics for associated nausea/vomiting 2
• Ergot alkaloids 2

Important Considerations for Acute Treatment:

• Start treatment as early as possible during attack 1
• Monitor for medication overuse headache (use of simple analgesics >15 days/month or triptans/combination analgesics >10 days/month) 1
• Avoid opioids and butalbital-containing medications unless other options have failed 2
• Triptans are contraindicated in patients with:
  • Coronary artery disease
  • Prinzmetal's variant angina
  • Uncontrolled hypertension
  • History of stroke or TIA
  • Wolff-Parkinson-White syndrome 1, 3

Preventive Treatment

When to Consider Prevention:

• Severe debilitating headaches despite adequate acute treatment
• Inability to tolerate or contraindications to acute treatments
• Using acute treatments more frequently than recommended
• Patient preference 4

First-line Preventive Medications:

• Beta-blockers:
  • Propranolol (80-240 mg/day)
  • Timolol (20-30 mg/day) 1
• Anticonvulsants:
  • Topiramate (100 mg/day)
  • Divalproex sodium (500-1500 mg/day)
  • Sodium valproate (800-1500 mg/day) 1

Second-line Preventive Medications:

• Tricyclic antidepressants:
  • Amitriptyline (30-150 mg/day, start at 10-25 mg at bedtime) 1, 5
• SNRIs:
  • Venlafaxine 5
• ACE inhibitors:
  • Lisinopril 4
• ARBs:
  • Candesartan or telmisartan 4
• SSRIs:
  • Fluoxetine 4

Special Considerations for Prevention:

• Start at low doses and gradually increase until desired outcomes are achieved 4
• Allow 3-4 months to reach maximal efficacy 1
• Switch medication if adequate response not achieved after 2-3 months 4
• Valproate is contraindicated during pregnancy due to teratogenicity 1
• OnabotulinumtoxinA (Botox) is approved for chronic migraine prophylaxis 5

Lifestyle Modifications

• Sleep: Maintain regular sleep schedule 1, 6
• Diet:
  • Consistent meal times to avoid hunger
  • Adequate hydration
  • Limit caffeine intake 1, 6
• Exercise: Regular physical activity/aerobic exercise 1, 6
• Stress management:
  • Yoga
  • Cognitive-behavioral therapy
  • Mindfulness techniques 1, 6
• Trigger identification and avoidance:
  • Use a headache diary to track frequency, severity, triggers, and response to treatment 1
  • Common triggers include alcohol, anxiety, dehydration, excessive caffeine, eye strain, hunger, sleep deprivation, and stress 5, 6

Monitoring and Follow-up

• Use a headache diary to determine treatment efficacy and identify analgesic overuse 4, 1
• Regularly reassess the balance of benefits, harms, and costs of preventive treatment 4
• Monitor for side effects of medications and adjust dosing as needed 1

Treatment Algorithm

1. Assess severity and frequency of migraines
2. For acute treatment:
   • Mild to moderate: Start with acetaminophen or NSAIDs
   • Moderate to severe: Use triptan + NSAID combination
   • If ineffective: Try second-line agents (gepants, ditans, or ergot alkaloids)
3. For preventive treatment (if indicated):
   • First-line: Beta-blockers, topiramate, or divalproex sodium
   • If ineffective or not tolerated: Try second-line agents
   • Allow 2-3 months to assess efficacy before switching
4. Implement lifestyle modifications alongside pharmacological treatment
5. Monitor response using headache diary and adjust treatment as needed