What are the treatment options for migraine?

Treatment of Migraine

For acute migraine treatment, a stepped care approach should be used, starting with NSAIDs for mild to moderate attacks and progressing to triptans or combination therapy for moderate to severe attacks. 1, 2

Acute Treatment Options

First-Line Treatments

• For mild to moderate migraine attacks, use NSAIDs such as aspirin, ibuprofen, diclofenac, or naproxen 1, 2
• Acetaminophen is less effective than NSAIDs but can be used in patients who cannot tolerate NSAIDs 2
• For moderate to severe migraine attacks, use triptans (sumatriptan, rizatriptan, zolmitriptan, etc.) 1
• Combination therapy with a triptan plus an NSAID or acetaminophen is more effective than monotherapy and should be initiated as early as possible after headache onset 1, 2

Administration Tips

• Begin treatment as soon as possible after migraine onset for maximum efficacy 1, 2
• If one triptan is ineffective, try another triptan as patients may respond differently to various triptans 1, 2
• For patients with severe nausea or vomiting, use non-oral routes of administration (nasal spray, subcutaneous injection) and add an antiemetic 1
• Rizatriptan and sumatriptan have demonstrated efficacy in clinical trials with significant pain relief within 2 hours compared to placebo 3, 4

Second-Line Treatments

• For patients who don't respond to or cannot tolerate triptans plus NSAIDs, consider CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant 1, 5
• Dihydroergotamine (DHE) is another alternative when first-line treatments fail 1, 2

Third-Line Treatment

• Lasmiditan (ditan) can be considered for patients who don't respond to or cannot tolerate all other treatments 1, 5
• Note that patients taking lasmiditan should not operate machinery for at least 8 hours after intake due to potential impairment 1

Preventive Treatment

Indications for Preventive Therapy

• Consider preventive therapy for patients with:
  • Two or more migraine attacks per month producing significant disability 1, 2
  • Attacks that remain debilitating despite adequate acute treatment 1
  • Contraindication to or failure of acute treatments 2, 6
  • Use of acute medication more than twice per week or risk of medication overuse headache 1, 2

First-Line Preventive Medications

• Beta-blockers (propranolol) 1, 6
• Antiepileptics (topiramate) 1, 6
• Tricyclic antidepressants (amitriptyline) 1
• CGRP monoclonal antibodies 1, 6

Alternative Preventive Options

• ACE inhibitors (lisinopril) 1
• Angiotensin II receptor blockers (candesartan, telmisartan) 1
• SSRIs (fluoxetine) 1
• Nutraceuticals with evidence for efficacy: magnesium, riboflavin (vitamin B2), coenzyme Q10 6, 7

Important Cautions

Medications to Avoid

• Opioids and butalbital-containing medications should not be used for migraine treatment due to risk of dependency, rebound headaches, and loss of efficacy 1, 5, 8
• Oral ergot alkaloids are poorly effective and potentially toxic, and should not be used as a substitute for triptans 1

Safety Considerations

• Monitor for medication overuse headache, which can occur with frequent use of acute medications (≥15 days/month for NSAIDs, ≥10 days/month for triptans) 1, 2
• Triptans should be used with caution in patients with cardiovascular risk factors due to potential for coronary artery vasospasm 3
• Serotonin syndrome may occur with triptans, particularly during coadministration with SSRIs, SNRIs, TCAs, and MAO inhibitors 3

Lifestyle Modifications

• Identify and avoid personal migraine triggers through food diaries and lifestyle tracking 1, 2
• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 1, 7
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1, 2
• Manage stress with relaxation techniques or mindfulness practices 1, 2
• Consider behavioral interventions such as cognitive behavioral therapy, relaxation training, or biofeedback 1, 6