What are the treatment options for migraine?

Migraine Treatment Options

Migraine treatment should follow a stepped care approach, starting with NSAIDs for mild to moderate attacks and progressing to triptans or combination therapy for moderate to severe attacks, while preventive therapy should be considered for patients with frequent or disabling headaches. 1

Acute Treatment

First-Line Options

• NSAIDs are recommended as first-line treatment for mild to moderate migraine attacks 2, 1
  • Ibuprofen is effective for pain relief in both children and adolescents 2
  • Aspirin-acetaminophen-caffeine combination has strong evidence for efficacy with a number needed to treat of 9 for pain freedom at 2 hours 2

Second-Line Options

• Triptans are recommended when NSAIDs provide inadequate relief 1, 3
  • Sumatriptan has demonstrated significant headache response rates at 2 and 4 hours compared to placebo 3
  • For adolescents, consider sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral 2
  • Triptans are most effective when taken early while headache is still mild 1, 3
  • If one triptan is ineffective, try another or a NSAID-triptan combination 2

Advanced Treatment Options

• For patients who fail triptans or have contraindications:
  • CGRP antagonists (gepants) like ubrogepant and rimegepant have shown moderate efficacy with a number needed to treat of 13 for pain freedom at 2 hours 2, 1
  • Lasmiditan (ditan) shows benefit for pain freedom but has significant adverse effects including driving restrictions 2

Managing Associated Symptoms

• For nausea/vomiting, use non-oral routes of administration:
  • Non-oral triptans (nasal or subcutaneous) are recommended 2
  • Consider antiemetics to treat nausea and improve gastric motility 1

Preventive Treatment

Indications for Prevention

• Consider preventive therapy for patients with:
  • Frequent or disabling headaches 2
  • Medication overuse headache 2
  • Failure of or contraindication to acute treatments 1, 4
  • Two or more attacks per month producing disability lasting 3+ days per month 1

First-Line Preventive Options

• Evidence-based preventive medications include:
  • Topiramate (first-line for chronic migraine due to efficacy and lower cost) 2
  • Beta-blockers (propranolol) 1
  • Amitriptyline combined with cognitive behavioral therapy 2
  • CGRP monoclonal antibodies for patients who have failed at least two other preventive medications 2
  • OnabotulinumtoxinA for chronic migraine 2

Second-Line Preventive Options

• Additional options with less robust evidence include:
  • Candesartan 2
  • Nutraceuticals: riboflavin, coenzyme Q10, and magnesium 1, 5
  • Venlafaxine 6

Non-Pharmacological Approaches

Lifestyle Modifications

• Advise patients on lifestyle factors and migraine triggers 2
• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 1, 5
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1, 5
• Manage stress with relaxation techniques or mindfulness practices 1

Behavioral Interventions

• Cognitive behavioral therapy has shown efficacy, especially when combined with amitriptyline 2
• Biofeedback and relaxation therapy can be effective non-pharmacological options 7, 5

Important Cautions

Medication Overuse

• Limit acute medication use to prevent medication overuse headache:
  • ≤15 days/month for NSAIDs
  • ≤10 days/month for triptans 1
• Educate patients about the risk of medication overuse headache 2

Safety Considerations

• Triptans are contraindicated in patients with:
  • Coronary artery disease
  • Prinzmetal's variant angina
  • Wolff-Parkinson-White syndrome
  • History of stroke or TIA 3
• Discuss teratogenic effects of topiramate and valproate with patients of childbearing potential, and advise effective birth control methods and folate supplementation 2
• Monitor for serotonin syndrome when triptans are used with SSRIs, SNRIs, TCAs, or MAO inhibitors 3

Managing Comorbidities

• Identify and address comorbid conditions such as anxiety, depression, sleep disturbances, and obesity 2
• Select preventive medications based on comorbidities:
  • Topiramate for patients with obesity due to its association with weight loss
  • Amitriptyline for patients with depression or sleep disturbances 2