What are the treatment options for migraine?

Treatment Options for Migraine

The most effective approach for treating moderate to severe migraine attacks is a triptan + NSAID combination started as early as possible after migraine onset, with sumatriptan subcutaneous injection providing the fastest relief. 1

Acute Migraine Treatment

First-line options:

• For mild to moderate attacks:

  • Acetaminophen (paracetamol): 650-1000 mg every 4-6 hours (max 4g/day) 1
  • NSAIDs:
    • Ibuprofen: 400 mg (more effective than 200 mg) 1, 2
    • Naproxen sodium
    • Diclofenac potassium
    • Aspirin (acetylsalicylic acid)

• For moderate to severe attacks:

  • Triptans:
    • Sumatriptan: oral (25-100 mg), subcutaneous (6 mg), or intranasal 3
    • Rizatriptan
    • Eletriptan
    • Zolmitriptan
    • Almotriptan
    • Frovatriptan
    • Naratriptan

Clinical pearl: Soluble formulations of ibuprofen 400 mg provide more rapid relief than standard tablets 2

Second-line options:

• CGRP antagonists (when triptans fail or are contraindicated):
  • Rimegepant
  • Ubrogepant
  • Zavegepant 1

Refractory migraine options:

• Triptan + NSAID combination used simultaneously
• Dihydroergotamine (DHE)
• Antiemetics (for associated symptoms or as rescue)
• Corticosteroids (as rescue medication) 4

Preventive Treatment

When to consider prevention:

• Migraines occurring ≥2 days per month with significant impact despite optimized acute treatment
• Severe debilitating headaches despite adequate acute treatment
• Contraindications to acute treatments
• Using acute treatments more frequently than recommended (risk of medication overuse headache) 1

First-line preventive medications:

• Beta blockers:

  • Propranolol: 80-240 mg/day
  • Timolol: 20-30 mg/day
  • Metoprolol
  • Avoid beta blockers with intrinsic sympathomimetic activity 1

• Antidepressants:

  • Amitriptyline: 30-150 mg/day 1

• Antiseizure medications:

  • Divalproex sodium: 500-1500 mg/day
  • Sodium valproate: 800-1500 mg/day
  • Topiramate: 100 mg/day 1

Second/third-line preventive options:

• CGRP antagonists and CGRP monoclonal antibodies 1
• Serotonin and norepinephrine reuptake inhibitors 1

Important: Start preventive medications at a low dose and gradually increase until desired outcomes are achieved. Allow 2-3 months to assess efficacy and 3-4 months to reach maximal effect. 1

Non-pharmacological Approaches

Lifestyle modifications:

• Regular sleep schedule
• Consistent meal times
• Adequate hydration
• Limited caffeine intake 1

Physical activity:

• Aerobic exercise: 40 minutes, three times weekly
• Progressive strength training: 2-3 times weekly for 30-60 minutes 1

Behavioral interventions:

• Stress management techniques:
  • Yoga
  • Cognitive-behavioral therapy
  • Mindfulness
• Physical therapy (especially for tension-type headache):
  • Thermal methods
  • Trigger point massage
  • Mobilization/manipulation 1

Special Considerations

Medication overuse headache:

• Defined as use of simple analgesics >15 days/month or triptans/combination analgesics >10 days/month
• Requires detoxification and withdrawal of overused medications 1, 3

Drug interactions and contraindications:

• Triptans are contraindicated in:

  • Coronary artery disease
  • Prinzmetal's variant angina
  • Wolff-Parkinson-White syndrome
  • History of stroke or TIA
  • Uncontrolled hypertension 3

• Risk of serotonin syndrome when triptans are combined with:

  • SSRIs
  • SNRIs
  • TCAs
  • MAO inhibitors 3

When to refer to specialist care:

• Insufficient pain relief with acute medications
• Uncertain diagnosis
• Significant comorbidities
• Treatment ineffective despite appropriate interventions 1