What are the treatment options for migraines?

Treatment Options for Migraines

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, 3

Acute Treatment of Migraines

First-Line Treatment

• For mild to moderate migraine attacks, use NSAIDs such as ibuprofen, aspirin, diclofenac, or naproxen as first-line therapy 1, 2, 4
• Acetaminophen (paracetamol) has less efficacy than NSAIDs but can be used in patients who cannot tolerate NSAIDs 2
• Combination analgesics containing caffeine (e.g., aspirin plus acetaminophen plus caffeine) are effective for mild attacks 2, 3
• Treatment should begin as early as possible during an attack for maximum efficacy 1, 2

Second-Line Treatment

• For moderate to severe attacks or when NSAIDs are ineffective, triptans are recommended (sumatriptan, rizatriptan, naratriptan, zolmitriptan, etc.) 1, 2, 5
• Triptans are most effective when taken early in an attack while headache is still mild 2, 6
• If one triptan is ineffective, try another triptan as individual responses vary 1, 2
• Combining a triptan with an NSAID or acetaminophen improves efficacy 1, 2
• For patients with severe nausea/vomiting, use non-oral routes of administration (nasal, subcutaneous) and consider adding an antiemetic 1, 3

Third-Line Treatment

• For patients who fail triptans or have contraindications to their use, consider CGRP antagonists (gepants) like rimegepant, ubrogepant, or zavegepant 1, 3
• Dihydroergotamine (DHE) is an alternative when first-line treatments fail 1, 3
• Lasmiditan (ditan) can be considered for patients who don't respond to or cannot tolerate all other treatments 1, 3

Important Cautions

• Avoid opioids and butalbital-containing medications for acute migraine treatment due to risk of dependency, rebound headaches, and loss of efficacy 1, 3, 5
• 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 are contraindicated in patients with coronary artery disease, Prinzmetal's variant angina, uncontrolled hypertension, and history of stroke or TIA 6

Preventive Treatment of Migraines

Indications for Preventive Therapy

• Consider preventive therapy for patients with frequent migraine attacks (typically ≥4 headache days per month), significant disability, contraindication to or failure of acute treatments, or overuse of acute medications 1, 2, 7

First-Line Preventive Medications

• Beta-blockers (propranolol, metoprolol, timolol) 1, 7
• Anticonvulsants (topiramate, divalproex sodium/valproate) 1, 7
• CGRP monoclonal antibodies (e.g., galcanezumab) have shown efficacy in reducing monthly migraine days 8, 7
• Amitriptyline (tricyclic antidepressant) combined with cognitive behavioral therapy 1, 7

Second-Line Preventive Options

• ACE inhibitors (lisinopril) 1
• ARBs (candesartan, telmisartan) 1
• SSRIs (fluoxetine) 1
• OnabotulinumtoxinA (Botox) for chronic migraine 7

Non-Pharmacological Approaches

• Identify and manage migraine triggers (alcohol, stress, dehydration, sleep deprivation, etc.) 1, 2, 9
• Maintain regular sleep, eating, and exercise patterns 1, 2, 9
• Consider cognitive behavioral therapy, biofeedback, or relaxation techniques 2, 10, 9
• Dietary supplements with some evidence of efficacy include riboflavin, coenzyme Q10, and magnesium 2, 10, 9

Special Considerations

Pregnancy and Breastfeeding

• Discuss medication risks during pregnancy and lactation with patients of childbearing potential 1
• When relevant, discuss teratogenic effects of topiramate and valproate, and advise patients to use effective birth control methods and take folate 1

Children and Adolescents

• Use ibuprofen to treat pain in children/adolescents 1
• In adolescents, consider sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral 1
• Discuss the evidence for and side effects of amitriptyline combined with cognitive behavioral therapy, topiramate, and propranolol for migraine prevention in children/adolescents 1

Treatment Monitoring

• The use of a headache diary helps determine treatment efficacy, identify analgesic overuse, and follow up on migraine progression 1
• Consider reevaluating the balance of benefits, harms, and costs of preventive treatment periodically 1

By following this stepped approach to migraine management, focusing on both acute and preventive strategies, most patients can achieve significant improvement in migraine control and quality of life.