What are the treatment options for migraines?

Migraine Treatment Options

For acute migraine treatment, a stepped care approach should be used, starting with NSAIDs for mild to moderate attacks and progressing to triptans or combination therapy for moderate to severe attacks. 1

Acute Treatment Strategy

First-Line Therapy (Mild to Moderate Attacks)

• Over-the-counter NSAIDs with proven efficacy include acetylsalicylic acid (aspirin), ibuprofen, and diclofenac potassium 1
• Ibuprofen 400 mg provides pain relief in about half of sufferers, with NNT of 3.2 for 2-hour headache relief 2
• Paracetamol (acetaminophen) has less efficacy and should be used only in those who are intolerant of NSAIDs 1
• Combination analgesics containing caffeine can be effective for mild attacks 1

Second-Line Therapy (Moderate to Severe Attacks)

• Triptans should be offered to patients for whom over-the-counter analgesics provide inadequate headache relief 1
• Triptans are most effective when taken early in an attack while headache is still mild 1
• If one triptan is ineffective, others might still provide relief 1
• Sumatriptan has well-documented effectiveness with significant headache response at 2 and 4 hours compared to placebo 3

Combination Therapy

• Combining a triptan with an NSAID or acetaminophen improves efficacy 1
• Patients should begin treatment as soon as possible after migraine onset using combination therapy 1

Third-Line Therapy

• For patients who fail all available triptans or have contraindications to triptans:
  • CGRP antagonists (gepants) like rimegepant, ubrogepant, or zavegepant 1
  • Dihydroergotamine (DHE) 1
  • Lasmiditan (ditan) for patients who don't respond to other treatments 1

Special Considerations

For Migraine with Nausea/Vomiting

• Use non-oral routes of administration 1
• Consider antiemetics like metoclopramide or prochlorperazine to treat accompanying nausea and improve gastric motility 1
• Subcutaneous sumatriptan injection can be useful for patients who cannot take oral triptans due to vomiting 1

Important Cautions

• Avoid opioids and butalbital-containing analgesics for migraine treatment 1
• Limit acute medication use to prevent medication overuse headache (≤15 days/month for NSAIDs, ≤10 days/month for triptans) 1
• Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's variant angina, uncontrolled hypertension, and history of stroke or TIA 3
• Monitor for serotonin syndrome when triptans are used with SSRIs, SNRIs, TCAs, or MAO inhibitors 3

Preventive Treatment

• Consider preventive therapy for patients with:
  • Two or more attacks per month producing disability lasting 3+ days per month 1
  • Contraindication to or failure of acute treatments 1
  • Use of acute medication more than twice per week 1
  • Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 1

Lifestyle Modifications

• Address predisposing factors such as poor sleep quality, poor physical fitness, or stress 1
• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 1
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1
• Manage stress with relaxation techniques or mindfulness practices 1

By following this stepped care approach and individualizing treatment based on attack severity, associated symptoms, and patient response, most migraine sufferers can achieve significant relief from their attacks and improved quality of life.