What are the treatment options for migraine?

Treatment of Migraine Headaches

The most effective approach for migraine treatment is a stepped care strategy, starting with NSAIDs for mild to moderate attacks and progressing to triptans or combination therapy for moderate to severe attacks. 1

Acute Treatment Options

First-Line Treatments

• For mild to moderate migraine attacks, use NSAIDs such as ibuprofen 400-800mg, naproxen sodium 275-550mg, or aspirin 650-1000mg 1, 2
• Acetaminophen has less efficacy than NSAIDs and should only be used in patients who cannot tolerate NSAIDs 1
• Combination analgesics containing caffeine can be effective for mild attacks 1, 2
• For moderate to severe attacks, triptans are recommended as first-line therapy 1, 2
• Triptans are most effective when taken early in an attack while headache is still mild 1
• If one triptan is ineffective, others might still provide relief 1, 3
• Combining a triptan with an NSAID improves efficacy 1, 2

Second-Line Treatments

• CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant for patients who don't respond to or cannot tolerate triptans plus NSAIDs 1, 2
• Dihydroergotamine (DHE) is an alternative when first-line treatments fail 2
• Antiemetics like metoclopramide or prochlorperazine are recommended, particularly when migraine is accompanied by nausea/vomiting 1, 2

Treatment Considerations

• For patients with severe nausea/vomiting, use non-oral routes of administration such as nasal sprays or injections 1, 2
• Subcutaneous sumatriptan injection can be useful for patients who rapidly reach peak headache intensity or cannot take oral medications due to vomiting 2, 4
• Avoid opioids and butalbital-containing medications due to risk of dependency, rebound headaches, and loss of efficacy 1, 2
• Limit acute medication use to prevent medication overuse headache (≤15 days/month for NSAIDs, ≤10 days/month for triptans) 1, 3

Preventive Treatment

When to Consider Prevention

• Consider preventive therapy for patients with two or more attacks per month producing disability lasting 3+ days per month 1
• Preventive treatment is also indicated for patients with contraindication to or failure of acute treatments 1
• Patients using acute medication more than twice per week should be considered for preventive therapy 1, 5
• Preventive treatment is appropriate for patients with uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 1

Preventive Medication Options

• Beta-blockers, amitriptyline, and divalproex sodium have documented high efficacy with mild to moderate adverse events 5
• Topiramate is an effective option but requires discussion of teratogenic effects with patients of childbearing potential 6
• If recommended treatments are not tolerated or result in inadequate response, consider an ACE inhibitor (lisinopril), an ARB (candesartan or telmisartan), or an SSRI (fluoxetine) 6
• Start preventive medications at a low dose and gradually increase until desired outcomes are achieved 6

Lifestyle Modifications

• Address predisposing factors such as poor sleep quality, poor physical fitness, or stress 1
• 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

Special Considerations

Medication Overuse Headache

• Overuse of acute migraine drugs (e.g., ergotamine, triptans, opioids, or a combination of drugs for 10 or more days per month) may lead to exacerbation of headache 3
• Detoxification of patients, including withdrawal of the overused drugs, may be necessary 3

Cardiovascular Risk

• Triptans should not be given to patients with ischemic or vasospastic coronary artery disease 3
• Patients with multiple cardiovascular risk factors should have a cardiovascular evaluation prior to receiving triptans 3
• For patients with cardiovascular contraindications, gepants and ditans do not have vascular contraindications 7

Monitoring Treatment

• The use of a headache diary may help to determine treatment efficacy, identify analgesic overuse, and follow up on migraine progression 6
• Switch preventive treatment if an adequate response is not achieved during a reasonable trial period (generally 2 to 3 months), or earlier if an adverse effect occurs 6