What are the first-line drugs for migraine treatment?

First-Line Drugs for Migraine Treatment

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy for mild to moderate attacks, while triptans are first-line for moderate to severe attacks. 1, 2

First-Line Medications by Migraine Severity

Mild to Moderate Attacks:

• NSAIDs with proven efficacy: aspirin, ibuprofen, naproxen sodium, and the combination of acetaminophen plus aspirin plus caffeine 1, 2
• Acetaminophen alone lacks evidence for efficacy in migraine treatment 1, 2

Moderate to Severe Attacks:

• Triptans (serotonin 5-HT1B/1D agonists): oral sumatriptan, naratriptan, rizatriptan, and zolmitriptan 1, 2
• Subcutaneous sumatriptan and dihydroergotamine (DHE) nasal spray have good evidence for efficacy 1, 2

Treatment Algorithm

1. For mild to moderate attacks:

   • Start with NSAIDs (aspirin, ibuprofen, naproxen sodium) 1, 2
   • If inadequate response within 2 hours, escalate to a triptan 2

2. For moderate to severe attacks:

   • Start with a triptan (oral, nasal, or subcutaneous depending on symptoms) 1, 2
   • Consider DHE nasal spray as an alternative 1

3. For attacks with significant nausea/vomiting:

   • Select a non-oral route of administration (subcutaneous, nasal spray) 1, 2
   • Add an antiemetic medication even if vomiting is not present 1, 2

Special Considerations

• Triptans should not be used in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or those at risk for heart disease 1, 3
• When using oral medications in patients with nausea, consider adding an antiemetic to improve absorption 1, 2
• Limit acute treatments to no more than twice weekly to prevent medication-overuse headache 1, 3

Efficacy and Safety

• Triptans have good evidence for efficacy, with sumatriptan showing pain-free response rates significantly higher than placebo (NNT 5.1 for 100 mg dose) 4, 5
• NSAIDs are generally well-tolerated for short-term use 1
• Adverse events are more common with sumatriptan 100 mg compared to placebo (NNH 7.1) 5
• Combination of a triptan and a NSAID may yield better efficacy than either therapy alone 6

Alternative Formulations

• For patients who have difficulty swallowing pills or have significant nausea:
  • Orally disintegrating tablets (rizatriptan and zolmitriptan) 7
  • Intranasal sprays (sumatriptan and zolmitriptan) 7
  • Subcutaneous injection (sumatriptan) 1, 7

Common Pitfalls to Avoid

• Delaying treatment - early intervention is key to preventing central sensitization 7
• Using acetaminophen alone, which lacks evidence for efficacy 1, 2
• Overusing acute medications (>10 days/month), which can lead to medication-overuse headache 6
• Failing to address nausea, which is one of the most disabling symptoms 1, 2