What are the recommended treatments for migraine management?

Migraine Management: Treatment Strategies

For effective migraine management, a stepped care approach should be used, starting with NSAIDs for mild to moderate attacks and progressing to triptans for moderate to severe attacks. 1

Acute Treatment

First-Line Therapy

• For mild to moderate migraine attacks, NSAIDs are the first-line treatment with consistent evidence for efficacy 2
• Effective NSAIDs include:
  • Aspirin (650-1000 mg) 2
  • Ibuprofen (400-800 mg) 2, 1
  • Naproxen sodium (275-550 mg) 2
• Combination analgesics containing caffeine are also effective for mild attacks 2, 1
• Acetaminophen alone is NOT recommended for migraine treatment 2

Second-Line Therapy

• For moderate to severe migraine attacks or when NSAIDs fail, triptans are the treatment of choice 2, 1
• Effective triptans include:
  • Sumatriptan (oral and subcutaneous) 2, 3
  • Rizatriptan 2, 4
  • Naratriptan 2
  • Zolmitriptan 2
  • Eletriptan 3
• 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

Managing Associated Symptoms

• For migraines with significant nausea or vomiting, use non-oral routes of administration 2
• Antiemetics like metoclopramide or prochlorperazine should be used to treat accompanying nausea and improve gastric motility 2, 1

Preventive Treatment

Indications for Prevention

• Consider preventive therapy for patients with: 2, 1
  • Two or more attacks per month producing disability lasting 3+ days per month
  • Contraindication to or failure of acute treatments
  • Use of acute medication more than twice per week
  • Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura)

First-Line Preventive Options

• Topiramate has proven efficacy in chronic migraine prevention 2, 1
• Beta-blockers are commonly used in clinical practice 2
• For chronic migraine, options with evidence-based support include: 2
  • Topiramate
  • OnabotulinumtoxinA
  • CGRP monoclonal antibodies

Important Cautions and Pitfalls

Medication Overuse Headache

• Limit acute medication use to prevent medication overuse headache: 2, 1, 4
  • NSAIDs: ≤15 days/month
  • Triptans: ≤10 days/month
• Overuse of acute medications can lead to rebound headaches and eventual loss of efficacy 2

Medications to Avoid

• Opioids and butalbital-containing analgesics should be avoided for routine migraine treatment 2, 5
• Narcotic use should be avoided for chronic daily headaches due to risk of dependency, rebound headaches, and loss of efficacy 2

Triptan Contraindications

• Triptans should not be used in patients with: 4
  • Ischemic or vasospastic coronary artery disease
  • History of stroke or transient ischemic attack
  • Uncontrolled hypertension
  • Basilar or hemiplegic migraine

Lifestyle and Non-Pharmacological Approaches

• Address predisposing factors such as poor sleep quality, physical fitness, or stress 1, 6
• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 1, 6
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1, 6
• Manage stress with relaxation techniques or mindfulness practices 1, 6
• Consider dietary supplements such as riboflavin, coenzyme Q10, and magnesium for prevention 1, 6

Monitoring Treatment

• Use a headache diary to determine treatment efficacy, identify analgesic overuse, and follow migraine progression 1
• Switch preventive treatment if an adequate response is not achieved during a reasonable trial period (2-3 months) 2, 1