What are the best medications for migraine treatment?

Best Medications for Migraine Treatment

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line therapy for mild to moderate attacks, while triptans are first-line for moderate to severe attacks. 1, 2

Acute Treatment Algorithm

First-Line Options:

• For mild to moderate migraine attacks:

  • NSAIDs with the most consistent evidence for efficacy: 1
    • Aspirin (650-1000 mg)
    • Ibuprofen (400-800 mg)
    • Naproxen sodium
    • Combination of acetaminophen + aspirin + caffeine
  • Note: Acetaminophen alone is ineffective for migraine 1

• For moderate to severe migraine attacks or when NSAIDs fail:

  • Triptans (serotonin 5-HT1B/1D agonists): 1, 2
    • Sumatriptan (oral 25-100 mg, subcutaneous 6 mg)
    • Rizatriptan
    • Zolmitriptan
    • Naratriptan
    • Eletriptan

Special Considerations:

• For migraines with significant nausea/vomiting:

  • Use non-oral routes of administration 1
  • Add an antiemetic (e.g., metoclopramide, prochlorperazine) 1

• For rescue therapy when other treatments fail:

  • Opioid analgesics may be considered when other options have failed and risk of abuse is addressed 1
  • Note: Limit opioid use due to risk of dependency and rebound headaches 1

Efficacy of Key Medications

NSAIDs:

• Provide headache relief at 2 hours in approximately 30% of patients 1
• Less effective than triptans for moderate-severe attacks 2
• Fewer side effects than triptans 1

Triptans:

• Sumatriptan 100 mg provides pain-free response at 2 hours with NNT of 4.7 3
• Sumatriptan 50 mg provides headache relief at 2 hours with NNT of 3.2 4, 3
• Most effective when taken early in an attack 2, 3
• Subcutaneous sumatriptan (6 mg) provides relief within 1 hour in 70-80% of patients 5, 6

Preventive Treatment

Preventive therapy should be considered when: 1, 2

• Two or more migraine attacks per month with disability lasting 3+ days
• Acute medications are contraindicated or ineffective
• Medication overuse (using acute treatments more than twice weekly)
• Presence of uncommon migraine conditions (e.g., hemiplegic migraine)

First-Line Preventive Options:

• Beta-blockers (e.g., propranolol) 2
• Anticonvulsants (e.g., topiramate, divalproex sodium) 2
• Antidepressants (e.g., amitriptyline) 2

Second-Line Preventive Options:

• Calcium channel blockers (e.g., flunarizine 10 mg/day) 7, 2
• Note: Flunarizine may take 2-3 months to show benefit 7

Important Cautions

• Medication overuse headache:

  • Limit acute treatments to no more than twice weekly 1, 2
  • Overuse can lead to rebound headaches 1

• Triptan contraindications: 2, 8

  • Uncontrolled hypertension
  • Coronary artery disease
  • History of stroke
  • Hemiplegic or basilar migraine
  • Use within 24 hours of ergotamine or other triptans 8

• Timing of triptan administration:

  • Most effective when taken early in attack 2, 3
  • Should not be taken during aura phase 2

• Side effects of triptans:

  • Common: dizziness, weakness, drowsiness 8
  • Serious but rare: cardiovascular events 8, 9

By following this evidence-based approach to migraine treatment, most patients can achieve significant relief from migraine attacks and improved quality of life.