What are the treatment options for migraines?

Migraine Treatment Options

For acute migraine treatment, NSAIDs (aspirin 650-1000 mg, ibuprofen 400-800 mg, or naproxen 275-550 mg) and combination analgesics are first-line for mild to moderate attacks, while triptans are first-line for moderate to severe attacks, with triptan + NSAID combinations being most effective for severe attacks. 1

Acute Treatment Algorithm

Mild to Moderate Attacks

1. First-line options:

   • NSAIDs:
     • Aspirin 650-1000 mg
     • Ibuprofen 400-800 mg
     • Naproxen sodium 275-550 mg
     • Paracetamol (acetaminophen) 650-1000 mg every 4-6 hours (max 4g/day) 1
   • Combination analgesics (acetaminophen + aspirin + caffeine) 1

2. For attacks with significant nausea/vomiting:

   • Add antiemetics (metoclopramide or prochlorperazine)
   • Consider non-oral routes of administration 1

Moderate to Severe Attacks

1. First-line options:

   • Triptans:
     • Sumatriptan (25-100 mg)
     • Rizatriptan
     • Zolmitriptan
     • Naratriptan 1, 2
   • Triptan + NSAID combination (most effective approach) 1

2. Timing is crucial:

   • Start medication as soon as possible after migraine onset
   • Treating during mild pain phase provides better outcomes than waiting until pain is moderate/severe 3

Sumatriptan Efficacy

• 50 mg and 100 mg doses show significant efficacy over placebo
• 100 mg dose provides better pain-free response at 2 hours (NNT 4.7) compared to 50 mg dose (NNT 6.1) 3
• Headache response rates at 2 hours: 50-62% for 100 mg dose vs 27% for placebo 2
• Also effectively relieves associated symptoms (nausea, photophobia, phonophobia) 2, 3

Preventive Treatment

Consider preventive treatment if migraines occur ≥2 days per month with significant impact despite optimized acute treatment. 1

First-line Preventive Options

1. Beta-blockers:

   • Propranolol (80-240 mg/day)
   • Timolol (20-30 mg/day) 1

2. Antidepressants:

   • Amitriptyline (30-150 mg/day) - only antidepressant with consistent efficacy 1

3. Anticonvulsants:

   • Topiramate (100 mg/day) - strongest evidence for chronic migraine
   • Divalproex sodium (500-1500 mg/day)
   • Sodium valproate (800-1500 mg/day) 1

Lifestyle Modifications

• Regular sleep schedule
• Consistent meal times
• Adequate hydration
• Regular exercise program (aerobic exercise 40 minutes, 3x weekly)
• Progressive strength training (2-3x weekly, 30-60 minutes)
• Stress management techniques (yoga, CBT, mindfulness)
• Limited caffeine intake 1

Important Considerations and Cautions

Medication Overuse

• Monitor for medication overuse headache (simple analgesics >15 days/month or triptans/combination analgesics >10 days/month) 1
• Use headache diary to track medication use and effectiveness 1

Triptan Contraindications

• Contraindicated in:
  • Coronary artery disease
  • Prinzmetal's variant angina
  • Wolff-Parkinson-White syndrome
  • History of stroke or TIA
  • Uncontrolled hypertension 2

Adverse Effects of Triptans

• Common side effects include sensations of tightness, pain, pressure in chest/throat/neck/jaw
• Risk of serotonin syndrome when combined with SSRIs, SNRIs, TCAs, or MAOIs
• Can cause blood pressure elevation 2

When to Refer to Specialist

• Uncertain diagnosis
• Treatment ineffective despite appropriate interventions
• Significant comorbidities complicating management
• Medication overuse not manageable in primary care 1

Treatment Evaluation

• Evaluate effectiveness after 2-3 months
• For preventive treatments, allow 3-4 months to reach maximal efficacy
• Consider changing medication if inadequate response 1

Remember that early intervention in acute attacks and appropriate preventive therapy in eligible patients are key principles for effective migraine management.