What is the best medication for treating migraines?

Best Medications for Migraine Treatment

For migraine treatment, triptans (particularly sumatriptan) are the most effective first-line therapy for moderate to severe migraine attacks, while NSAIDs are recommended for mild to moderate attacks. 1

First-Line Treatment Options

For Mild to Moderate Migraines:

• NSAIDs are recommended as first-line therapy by the American Academy of Neurology 1
  • Ibuprofen: 400-800mg every 6-8 hours as needed 1
  • Aspirin: 650-1000mg every 4-6 hours (maximum daily dose: 4g) 2, 1
  • Naproxen sodium: effective for mild-moderate attacks 1
• Combination analgesics containing caffeine can be more effective than single agents alone 2, 1

For Moderate to Severe Migraines:

• Triptans are the first-line treatment for moderate to severe attacks 1
  • Sumatriptan: Most extensively studied triptan with proven efficacy
    • Available in multiple formulations (oral, subcutaneous, intranasal, rectal) 3
    • Oral doses: 25mg, 50mg, 100mg with 100mg showing greatest efficacy (NNT 4.7 for pain-free at 2 hours) 4
    • Subcutaneous administration provides fastest relief (59% pain-free at 2 hours vs 15% with placebo) 3
  • Rizatriptan: May have faster onset than sumatriptan (1 hour vs 2-2.5 hours) 5
• Ergot alkaloids (e.g., dihydroergotamine) are effective alternatives but generally considered second-line 1

Treatment Algorithm

1. Assess migraine severity:

   • Mild to moderate: Start with NSAIDs 1
   • Moderate to severe: Use triptans 1

2. For mild to moderate attacks:

   • First try: Ibuprofen 400-800mg OR Aspirin 900-1000mg 1
   • If inadequate response: Switch to combination analgesics with caffeine 2
   • If still inadequate: Move to triptan therapy 2, 1

3. For moderate to severe attacks:

   • First try: Sumatriptan 50mg or 100mg orally 1, 6
   • If rapid relief needed: Consider subcutaneous sumatriptan 6mg (fastest onset) 3
   • If nausea/vomiting present: Use non-oral routes (subcutaneous, intranasal) 1, 3

4. For treatment failures:

   • Try a different triptan 1
   • Consider combination therapy (triptan + NSAID) 1
   • For severe, refractory attacks: Consider rescue medications 2

Important Clinical Considerations

• Take triptans early in the attack for maximum effectiveness, but not during aura phase 1
• Limit acute treatments to no more than twice weekly to prevent medication overuse headache 1
• For patients with frequent migraines (≥2 attacks/month), consider preventive therapy 7
• First-line preventive options include beta-blockers (propranolol), anticonvulsants (topiramate), and candesartan 7
• Flunarizine is an effective second-line preventive option 7

Common Pitfalls to Avoid

• Overuse of acute medications can lead to medication overuse headache (rebound headaches) 2, 1
• Acetaminophen alone is not recommended for migraine treatment 2
• Opioids should be avoided for chronic migraine management due to risk of dependency and rebound headaches 2
• Triptans are contraindicated in patients with cardiovascular disease due to vasoconstrictive effects 8
• Failure to consider preventive therapy in patients with frequent or disabling attacks 7

Adverse Effects

• NSAIDs: Gastrointestinal upset, bleeding risk in susceptible patients 2
• Triptans: Generally well-tolerated with transient and mild side effects 4
  • Common effects include dizziness, drowsiness, and fatigue (usually <10% of patients) 5
  • Dose-dependent relationship with adverse events 4
• Subcutaneous administration of sumatriptan has higher efficacy but also higher rates of adverse events 3