What are the treatment options for migraines?

Migraine Treatment Options

The most effective first-line treatment for acute migraine is a stepped care approach, 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 Options

• For mild to moderate migraine attacks, use over-the-counter NSAIDs with proven efficacy including acetylsalicylic acid (aspirin), ibuprofen 400-800 mg, naproxen sodium 275-550 mg, or diclofenac potassium 1, 2
• Combination analgesics containing caffeine can be effective for mild attacks 1, 2
• Paracetamol (acetaminophen) has less efficacy and should be used only in patients who cannot tolerate NSAIDs 1
• For moderate to severe attacks, triptans (such as sumatriptan) are recommended as first-line treatment 1, 2
• Combination therapy with a triptan plus an NSAID or acetaminophen is most effective and should be initiated as early as possible after headache onset 2

Second-Line Options

• For patients who don't respond to or cannot tolerate triptans plus NSAIDs, CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant are recommended 1, 2
• Dihydroergotamine (DHE) is an alternative when first-line treatments fail 1, 2
• Antiemetics like metoclopramide or prochlorperazine are particularly useful when migraine is accompanied by nausea/vomiting 1, 2

Third-Line Options

• Lasmiditan (ditan) is recommended for patients who don't respond to or cannot tolerate all other treatments 1, 2
• Subcutaneous sumatriptan injection can be useful for patients who rapidly reach peak headache intensity or cannot take oral medications due to vomiting 1, 3

Key Treatment Principles

• Begin treatment as early as possible after migraine onset for maximum efficacy 1
• Triptans are most effective when taken early in an attack while headache is still mild 1
• If one triptan is ineffective, others within the same class might still provide relief 1
• For patients with severe nausea/vomiting, use non-oral routes of administration 1, 2

Important Cautions

• Avoid opioids and butalbital-containing medications due to risk of dependency, rebound headaches, and loss of efficacy 1, 2
• Limit acute medication use to prevent medication overuse headache (≤15 days/month for NSAIDs, ≤10 days/month for triptans) 1, 2
• Triptans are contraindicated in patients with:
  • Coronary artery disease and Prinzmetal's variant angina 3
  • Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders 3
  • History of stroke or TIA 3
  • Uncontrolled hypertension 3

Preventive Treatment

• Consider preventive therapy for patients with:
  • Two or more attacks per month producing disability lasting 3+ days per month
  • Contraindication to or failure of acute treatments
  • Use of acute medication more than twice per week
  • 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

Special Considerations

• Sumatriptan works by binding to 5-HT1B/1D receptors, causing cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release 3
• Significant elevation in blood pressure, including hypertensive crisis, has been reported with triptans 3
• Serotonin syndrome may occur with triptans, particularly during co-administration with SSRIs, SNRIs, TCAs, and MAO inhibitors 3