What are the treatment options for migraine?

Treatment Options for Migraine

The most effective approach to migraine treatment involves a stepped care strategy, starting with NSAIDs for mild to moderate attacks and progressing to triptans or combination therapy for moderate to severe attacks. 1

Acute Treatment

First-Line Options

• Over-the-counter NSAIDs with proven efficacy include acetylsalicylic acid (aspirin), ibuprofen, and diclofenac potassium for mild to moderate attacks 1
• Ibuprofen is particularly effective for treating pain in children and adolescents 2
• Paracetamol (acetaminophen) has less efficacy and should be used only in patients who are intolerant of NSAIDs 1
• Combination analgesics containing caffeine can be effective for mild attacks 1

Second-Line Options

• Triptans should be offered to patients for whom over-the-counter analgesics provide inadequate headache relief 1
• In adolescents, consider sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral 2
• Sumatriptan is available in multiple formulations:
  • Oral (25mg, 50mg, 100mg): The 50mg dose provides complete pain relief in approximately 28% of patients versus 11% with placebo 3
  • Subcutaneous (6mg): Most effective route, providing pain relief in 59% of patients versus 15% with placebo 3
  • Intranasal and rectal formulations are available for patients with nausea/vomiting 3
• If one triptan is ineffective, try another or a non-steroidal anti-inflammatory drug-triptan combination 2, 1

Important Treatment Principles

• Begin treatment as early as possible in an attack while headache is still mild 1, 3
• For patients with rapid onset of severe pain or significant nausea/vomiting, consider non-oral routes of administration 1, 4
• Add antiemetics like metoclopramide or prochlorperazine to treat accompanying nausea and improve gastric motility 1, 4
• Limit acute medication use to prevent medication overuse headache: ≤15 days/month for NSAIDs, ≤10 days/month for triptans 1
• Avoid opioids and butalbital-containing analgesics due to risk of dependence and medication overuse headache 1

Preventive Treatment

When to Consider Prevention

• 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
  • Frequent or disabling headaches or medication overuse 2

Preventive Medication Options

• First-line options include:
  • Topiramate 1, 5
  • Propranolol 2
  • Amitriptyline (particularly when combined with cognitive behavioral therapy) 2
• For chronic migraine, consider onabotulinumtoxinA 5
• For refractory cases, consider CGRP antagonists (erenumab, fremanezumab, galcanezumab) 5
• When prescribing topiramate or valproate to women of childbearing potential, discuss teratogenic effects and advise on effective birth control methods and folate supplementation 2

Lifestyle Modifications and Non-Pharmacological Approaches

• 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
• Advise patients and families on migraine triggers and avoidance of acute medication overuse 2

Special Considerations

Status Migrainosus

• For severe, continuous migraine lasting up to one week, intravenous corticosteroids are the mainstay of treatment 4
• Include antiemetics to treat accompanying nausea and improve gastric motility 4
• Consider parenteral NSAIDs such as ketorolac for their rapid onset of action 4

Medication Safety

• Sumatriptan is contraindicated in patients with:
  • Coronary artery disease or Prinzmetal's variant angina
  • Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders
  • History of stroke or TIA
  • Uncontrolled hypertension 6
• Monitor for serotonin syndrome when combining sumatriptan with SSRIs, SNRIs, TCAs, or MAO inhibitors 6
• In patients with mild to moderate hepatic impairment, maximum single dose of sumatriptan should not exceed 50mg 6

Medication Overuse Headache

• Limit acute medication use to prevent medication overuse headache 1, 6
• In cases of medication overuse, withdrawal of the overused medication is essential, though this may temporarily worsen symptoms 4