What are the treatment options for migraines without using opiates or Benadryl (diphenhydramine)?

Migraine Treatment Options Without Opiates or Diphenhydramine

For most migraine sufferers, non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment option when avoiding opiates and diphenhydramine. 1

First-Line Treatment Options

NSAIDs for Mild to Moderate Migraines

• Aspirin (650-1000 mg every 4-6 hours, max 4g daily) has consistent evidence for efficacy 1
• Ibuprofen (400-800 mg every 6 hours, max 2.4g daily) is effective for mild to moderate attacks 1
• Naproxen sodium (275-550 mg every 2-6 hours, max 1.5g daily) shows good efficacy 1
• Combination of acetaminophen-aspirin-caffeine is effective (acetaminophen alone is ineffective) 1

Antiemetics for Nausea Management

• Metoclopramide (10 mg IV or orally) can be used to treat accompanying nausea and improve gastric motility during attacks 1
• Prochlorperazine can effectively relieve headache pain as well as nausea 1

Second-Line Treatment Options

Migraine-Specific Medications

• Triptans should be used when NSAIDs fail to provide relief for moderate to severe migraines 1

  • Sumatriptan (25-100 mg orally; 50 mg may be as effective as 100 mg with fewer side effects) 2
  • Rizatriptan, naratriptan, and zolmitriptan have good evidence for efficacy 1
  • Maximum daily dose of sumatriptan is 200 mg in a 24-hour period 2

• Dihydroergotamine (DHE) nasal spray has good evidence for efficacy and safety 1

  • Particularly useful when nausea/vomiting is present early in the attack 1

Other Medication Options

• Isometheptene combinations (e.g., isometheptene, acetaminophen, and dichloralphenazone) can be effective for milder migraine headaches 1
• Intranasal lidocaine may be considered, though evidence is limited 1

Preventive Treatment Options

First-Line Preventive Medications

• Propranolol (80-240 mg daily) has strong evidence for efficacy 1
• Timolol (20-30 mg daily) is effective with tolerable side effects 1
• Amitriptyline (30-150 mg daily) is recommended as a first-line preventive agent 1
• Divalproex sodium (500-1500 mg daily) or sodium valproate (800-1500 mg daily) are effective options 1

Special Considerations

When to Consider Preventive Treatment

• Two or more migraine attacks per month with disability lasting 3+ days per month 1
• Use of acute medications more than twice per week 1
• Failure of or contraindications to acute treatments 1
• Presence of uncommon migraine conditions (e.g., hemiplegic migraine, prolonged aura) 1

Medication Overuse Headache Risk

• Limit acute treatment to no more than twice a week to prevent medication overuse headaches 1
• Overuse of acute migraine drugs (≥10 days/month for triptans; ≥15 days/month for NSAIDs) can lead to exacerbation of headaches 2

Route of Administration

• Select a non-oral route of administration when significant nausea or vomiting is present early in the attack 1
• Options include sumatriptan subcutaneous injection, DHE nasal spray, or antiemetics 1

Cautions and Contraindications

Triptan Contraindications

• Avoid triptans in patients with uncontrolled hypertension, coronary artery disease, basilar or hemiplegic migraine 1, 2
• Monitor for potential cardiovascular side effects, especially in patients with multiple risk factors 2
• Serotonin syndrome risk when combined with SSRIs, SNRIs, TCAs, or MAO inhibitors 2

NSAID Considerations

• Use with caution in patients with gastrointestinal issues, renal impairment, or aspirin/NSAID-induced asthma 1
• NSAIDs may be more effective when given early in the migraine attack 3

By following this evidence-based approach to migraine treatment without opiates or diphenhydramine, clinicians can effectively manage acute attacks while minimizing risks associated with medication overuse and adverse effects.