What are the treatment options for migraine?

Treatment Options for Migraine

The most effective treatment strategy for migraine involves 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

First-Line Options

• NSAIDs with proven efficacy include acetylsalicylic acid (aspirin), ibuprofen, and diclofenac potassium for mild to moderate attacks 1
• Paracetamol (acetaminophen) has less efficacy and should be reserved for patients who cannot tolerate 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, 2
• Sumatriptan is effective in doses of 25mg, 50mg, and 100mg, with 100mg showing the highest efficacy (pain-free response in 28% vs 11% with placebo) 3, 4
• Triptans are most effective when taken early in an attack while headache is still mild 1, 5
• If one triptan is ineffective, others might still provide relief 2, 1
• Subcutaneous sumatriptan shows the greatest efficacy for pain relief but has more adverse events 5

Advanced Options

• For patients who fail triptans or have contraindications, options include CGRP antagonists (gepants), dihydroergotamine (DHE), or lasmiditan (ditan) 1
• Non-oral routes of administration (nasal sprays, injections, suppositories) should be considered when significant nausea or vomiting is present 6, 5
• Antiemetics like metoclopramide or prochlorperazine can treat accompanying nausea and improve gastric motility 6

Preventive Treatment

Indications for Prevention

• Consider preventive therapy for patients with two or more attacks per month producing disability lasting 3+ days per month 1
• Other indications include contraindication to or failure of acute treatments, use of acute medication more than twice per week, or presence of uncommon migraine conditions 1

Preventive Options

• First-line options include topiramate, propranolol, and amitriptyline 2, 1
• OnabotulinumtoxinA is approved specifically for chronic migraine 7
• Anticuerpos monoclonales contra el CGRP (erenumab, fremanezumab, galcanezumab) are effective in patients who have failed at least two previous preventive medications 7

Important Considerations and Cautions

Medication Overuse

• Limit acute medication use to prevent medication overuse headache (≤15 days/month for NSAIDs, ≤10 days/month for triptans) 1, 3
• Avoid opioids and butalbital-containing analgesics for migraine treatment due to risk of dependency and rebound headaches 1, 6

Special Populations

• In patients with cardiovascular disease, avoid triptans due to contraindications in coronary artery disease and Prinzmetal's variant angina 3
• Triptans are contraindicated in patients with uncontrolled hypertension, history of stroke or TIA, and Wolff-Parkinson-White syndrome 3
• For pregnant patients, acetaminophen and antiemetics are preferred; avoid NSAIDs and triptans 6

Adverse Effects

• Triptans may cause sensations of tightness, pain, pressure, and heaviness in the precordium, throat, neck, and jaw 3
• Serotonin syndrome may occur with triptans, particularly during co-administration with SSRIs, SNRIs, TCAs, and MAO inhibitors 3
• Adverse events with sumatriptan are generally mild to moderate and of short duration, but increase with higher doses 3, 5

Lifestyle Modifications

• 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
• Identify and avoid individual migraine triggers 2

Treatment Algorithm

1. For mild to moderate attacks: Start with NSAIDs (ibuprofen, aspirin, diclofenac) 1
2. For moderate to severe attacks or inadequate response to NSAIDs: Use triptans (sumatriptan 50-100mg) 1, 3
3. For attacks with significant nausea/vomiting: Add antiemetic and consider non-oral route of administration 6
4. For inadequate response to one triptan: Try another triptan or triptan-NSAID combination 2, 1
5. For frequent attacks (≥2/month): Consider preventive therapy 1