What are the treatment options for migraines?

Migraine Treatment Options

For migraine treatment, a stepped care approach should be used, starting with NSAIDs for mild to moderate attacks and progressing to triptans or combination therapy for moderate to severe attacks. 1, 2

Acute Treatment Algorithm

First-Line Treatment

• NSAIDs are recommended as first-line therapy for most patients with mild to moderate migraine attacks, with options including aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 2
• Combination analgesics containing caffeine (acetaminophen plus aspirin plus caffeine) are effective for mild attacks, but acetaminophen alone has less efficacy 1, 2
• Treatment should begin as early as possible during an attack for maximum efficacy 1, 2

Second-Line Treatment

• Triptans should be offered to patients for whom over-the-counter analgesics provide inadequate headache relief 1, 2
• Triptans are most effective when taken early in an attack while headache is still mild 1, 2
• If one triptan is ineffective, others might still provide relief 1
• Combining a triptan with an NSAID or acetaminophen improves efficacy 1, 2

Third-Line Treatment

• For patients who fail all available triptans or have contraindications to triptans, options include CGRP antagonists (gepants) like rimegepant, ubrogepant, or zavegepant; dihydroergotamine (DHE); or lasmiditan (ditan) 1, 2
• Subcutaneous sumatriptan injection can be useful for patients who cannot take oral triptans due to vomiting 1

Managing Associated Symptoms

• Use non-oral routes of administration for patients with migraine accompanied by nausea/vomiting 1, 2
• Consider antiemetics like metoclopramide or prochlorperazine to treat accompanying nausea and improve gastric motility 1, 2

Important Cautions

• Avoid opioids and butalbital-containing analgesics for migraine treatment 1, 2
• Limit acute medication use to prevent medication overuse headache (≤15 days/month for NSAIDs, ≤10 days/month for triptans) 1, 2
• Triptans (sumatriptan, eletriptan, etc.) have important contraindications including:
  • Coronary artery disease or Prinzmetal's variant angina 3, 4
  • History of stroke or TIA 3, 4
  • Uncontrolled hypertension 3, 4
  • Wolff-Parkinson-White syndrome or other cardiac conduction disorders 3, 4
• Monitor for serotonin syndrome when triptans are used with SSRIs, SNRIs, TCAs, or MAO inhibitors 3, 4

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
  • Contraindication to or failure of acute treatments 1
  • Use of acute medication more than twice per week 1
  • Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 1

Preventive Medication Options

• First-line preventive options include:
  • Beta-blockers (propranolol, timolol, metoprolol) 1, 5
  • Anticonvulsants (topiramate, divalproex sodium/sodium valproate) 1, 5
  • Topiramate requires discussion of teratogenic effects with patients of childbearing potential 1
• Second-line options include:
  • Tricyclic antidepressants (amitriptyline) 1, 5
  • SNRIs (venlafaxine) 1
  • ACE inhibitors or ARBs (candesartan) 1, 6
• Complementary treatments with evidence of effectiveness include:
  • Petasites, feverfew, magnesium, and riboflavin 5

Lifestyle Modifications

• Address predisposing factors such as poor sleep quality, poor physical fitness, or stress 1, 2, 6
• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 1, 2, 6
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1, 2, 6
• Manage stress with relaxation techniques or mindfulness practices 1, 2, 6

Treatment Monitoring

• Monitor treatment using a headache diary to determine efficacy, identify analgesic overuse, and follow migraine progression 1
• Switch preventive treatment if an adequate response is not achieved during a reasonable trial period 1