What is the treatment for migraines?

Treatment of Migraines

For acute migraine treatment, combination therapy of a triptan and an NSAID or acetaminophen is recommended for nonpregnant adults with inadequate response to NSAID or acetaminophen monotherapy, as this provides superior relief compared to monotherapy. 1, 2

First-Line Treatment Algorithm

Mild to Moderate Migraine Attacks

1. NSAIDs or Acetaminophen

   • Ibuprofen 400-600mg
   • Naproxen sodium 500-550mg
   • Aspirin 800-1000mg
   • Acetaminophen (appropriate dosage) 2

2. If inadequate response:

   • Consider increasing dosage (without exceeding maximum daily dose)
   • Add a triptan (see combination therapy below) 1

Moderate to Severe Migraine Attacks

1. Triptan monotherapy (effective but less beneficial than combination therapy)

   • Sumatriptan 50mg orally (for most patients)
   • Sumatriptan 6mg subcutaneously (for severe attacks or significant nausea/vomiting)
   • Rizatriptan 10mg orally 2, 3

2. Preferred: Combination therapy

   • Triptan (sumatriptan or rizatriptan) + NSAID (naproxen) OR
   • Triptan + acetaminophen 1, 2

Second-Line Options

• CGRP Antagonists (Gepants) such as rimegepant, ubrogepant, or zavegepant
• Ditans (lasmiditan)
• Antiemetics (for associated nausea/vomiting) 2

Evidence Quality and Effectiveness

The American College of Physicians' 2025 clinical guideline provides strong evidence that combination therapy of a triptan with an NSAID or acetaminophen has greater net benefit than triptan monotherapy 1. Clinical trials demonstrate that sumatriptan is effective in 50-67% of patients with oral administration and 70-80% with subcutaneous administration 3, 4.

Triptans work rapidly, with headache relief often beginning within 1-2 hours of administration. FDA data shows that sumatriptan provides headache response (reduction from moderate/severe to mild/no pain) in 50-62% of patients at 2 hours and 65-79% at 4 hours, compared to only 17-27% with placebo at 2 hours 3.

Important Considerations and Caveats

Timing of Administration

• Begin treatment as early as possible after headache onset for best results 2
• Medications are most effective when taken during the mild pain phase rather than waiting until pain is severe

Medication Overuse Prevention

Limit acute medications to prevent medication overuse headache:

• Triptans: No more than 9 days per month
• NSAIDs: No more than 15 days per month
• OTC medications: No more than 14 days per month 2

Contraindications

• Triptans are contraindicated in patients with ischemic heart disease, angina, previous myocardial infarction, and uncontrolled hypertension 4
• For patients with vascular contraindications, gepants and ditans may be appropriate alternatives as they don't have vascular contraindications 5

Recurrence Management

Approximately 40% of patients who initially respond to sumatriptan may experience headache recurrence within 24 hours, but most respond well to a second dose 4

Preventive Treatment

For patients with frequent migraines (≥2 attacks per month with disability lasting ≥3 days), consider preventive therapy:

• First-line preventive options:

  • Beta blockers (propranolol is FDA-approved for migraine prophylaxis) 6
  • Topiramate
  • Candesartan
  • Amitriptyline
  • Divalproex sodium 2

• For chronic migraine prevention:

  • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 2

Non-Pharmacological Approaches

• Regular exercise (aerobic, strength training, yoga)
• Sleep hygiene education
• Adequate hydration
• Identification and avoidance of triggers
• Relaxation techniques or mindfulness
• Cognitive Behavioral Therapy 2

These non-pharmacological approaches should complement, not replace, appropriate pharmacological treatment for acute attacks.