What are the treatment options for migraine headaches?

Treatment Options for Migraine Headaches

For acute migraine attacks, combination therapy with a triptan plus an NSAID or acetaminophen should be initiated as soon as possible after headache onset as first-line treatment for moderate to severe migraines. 1

Acute Treatment Algorithm

First-Line Options

1. Mild to Moderate Migraine:

   • NSAIDs (aspirin, diclofenac potassium, ibuprofen 400-600mg, naproxen sodium 500-550mg) 2
   • Acetaminophen (1000mg)
   • Combination of NSAID + acetaminophen

2. Moderate to Severe Migraine:

   • Triptan + NSAID/acetaminophen combination 1, 2
   • Common triptans with dosing:
     • Sumatriptan: 50-100mg orally, 6mg subcutaneously for severe attacks 2, 3
     • Rizatriptan: 10mg orally 2
     • Zolmitriptan: 2.5-5mg orally 1

Second-Line Options

For patients who don't respond to or cannot tolerate first-line treatments:

1. CGRP Antagonists (Gepants) 1, 2:

   • Rimegepant
   • Ubrogepant
   • Zavegepant

2. Ergot Alkaloids 1:

   • Dihydroergotamine (intranasal or injectable)

3. Ditans 2:

   • Lasmiditan (for patients with contraindications to triptans)

Route of Administration Considerations

• For severe nausea/vomiting: Use non-oral triptans (subcutaneous, intranasal) with antiemetics 1, 4
• Subcutaneous sumatriptan: Most effective for rapid pain relief (59% pain-free at 2 hours vs 15% with placebo) 4
• Oral sumatriptan: 100mg provides better pain relief than 50mg (NNT 3.5 vs 6.1 for pain-free at 2 hours) 5

Preventive Treatment

Consider preventive therapy if:

• Two or more migraine attacks per month with disability lasting 3+ days
• Inadequate response to acute treatments
• Use of acute medications more than twice weekly 2

First-line preventive options:

• Beta-blockers (propranolol) 1, 2
• Topiramate
• Candesartan
• Amitriptyline
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 2

Non-Pharmacological Approaches

• Regular aerobic exercise and strength training 2
• Maintaining regular sleep schedule
• Adequate hydration
• Relaxation techniques and mindfulness
• Cognitive-behavioral therapy 2
• Biofeedback combined with relaxation training 1, 2

Important Cautions and Contraindications

1. Do not use opioids or butalbital for acute migraine treatment 1, 2

2. Triptan contraindications:

   • Coronary artery disease
   • Uncontrolled hypertension
   • Concurrent use of MAOIs 3, 6

3. Medication overuse headache risk:

   • Limit triptans to ≤9 days per month
   • Limit NSAIDs to ≤15 days per month 2

4. Serotonin syndrome risk:

   • Monitor patients taking triptans with SSRIs or SNRIs 6
   • Watch for mental status changes, autonomic instability, neuromuscular symptoms

Special Populations

• Pregnancy: Metoclopramide for nausea; acetaminophen is safest for pain; sumatriptan may be used under specialist supervision 2
• Vascular contraindications: Consider NSAIDs, gepants, or ditans instead of triptans 2, 7

Early treatment during the mild pain phase provides significantly better outcomes than treating established attacks with moderate or severe pain 5. The stratified-care approach (assigning treatment based on migraine severity) is superior to the step-care approach (starting with safest, least expensive options) 1.