What is the best treatment for migraines?

Best Treatment for Migraines

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy for acute attacks, while preventive therapy should be considered for patients with frequent or disabling migraines. 1

Acute Treatment

First-Line Options

• NSAIDs are first-line therapy for most migraine sufferers, with consistent evidence supporting aspirin, ibuprofen, naproxen sodium, and the combination of acetaminophen plus aspirin plus caffeine 1
• Acetaminophen alone is ineffective for migraine treatment 1
• Treatment should be initiated early in the migraine attack for best results 1

Second-Line Options

• For patients whose migraine attacks do not respond to NSAIDs, use migraine-specific agents such as triptans or dihydroergotamine (DHE) 1
• Triptans with good evidence of efficacy include oral naratriptan, rizatriptan, zolmitriptan, and oral/subcutaneous sumatriptan 1, 2
• Sumatriptan has demonstrated significant headache response rates of 50-62% at 2 hours and 65-79% at 4 hours compared to placebo (17-27% at 2 hours and 19-38% at 4 hours) 2
• Triptans work by binding to 5-HT1B/1D receptors, causing cranial vessel constriction and inhibiting pro-inflammatory neuropeptide release 2

Special Considerations

• Select a non-oral route of administration when nausea or vomiting is a significant component of the migraine attack 1
• Treat nausea with an antiemetic; nausea itself is one of the most aversive and disabling symptoms of migraine 1
• Avoid triptans in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or cardiovascular disease risk factors 1, 3
• For status migrainosus (severe, continuous migraine lasting up to one week), systemic steroid therapy is the treatment of choice 4

Preventive Treatment

Indications for Prevention

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

First-Line Preventive Medications

• Recommended first-line agents with proven efficacy include: 1
  • Propranolol (80 to 240 mg/day)
  • Timolol (20 to 30 mg/day)
  • Amitriptyline (30 to 150 mg/day)
  • Divalproex sodium (500 to 1500 mg/day)
  • Sodium valproate (800 to 1500 mg/day)
  • Topiramate (for adults)

Other Preventive Options

• There is fair evidence for modest efficacy of magnesium, riboflavin, and feverfew in certain circumstances 1
• Beta-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol) are ineffective for migraine prevention 1
• Flunarizine (10 mg/day) has proven efficacy but is not available in the United States 1
• Clonidine has been shown to be ineffective for migraine prevention 1

Treatment Algorithm

For Acute Migraine:

1. Mild to moderate attacks: Start with NSAIDs (aspirin, ibuprofen, naproxen sodium) 1, 5
2. Moderate to severe attacks or NSAID failure: Use triptans (sumatriptan, rizatriptan, zolmitriptan) 1, 5
3. With significant nausea/vomiting: Add antiemetic and consider non-oral route of administration 1
4. Refractory attacks: Consider DHE nasal spray, oral opiate combinations, or butorphanol (when sedation and abuse risk are addressed) 1

For Preventive Therapy:

1. Initiate with low dose and titrate slowly until clinical benefits are achieved or limited by adverse events 1
2. Allow adequate trial period (2-3 months) to determine efficacy 1, 6
3. Avoid interfering medications such as overused acute medications 1, 6
4. Consider tapering or discontinuing after a period of stability 1

Common Pitfalls and Caveats

• Medication overuse can lead to rebound headaches and chronic daily headaches 1, 3
• Opioids should be limited due to risk of dependency, rebound headaches, and eventual loss of efficacy 4, 5
• Preventive therapy is underutilized despite more than 1 in 4 migraine patients being candidates 7
• Teratogenic effects of topiramate and valproate should be discussed with women of childbearing potential 1
• Triptans may cause non-coronary vasospastic reactions and should be used with caution 3