What are the treatment options for migraines?

Treatment Options for Migraines

For acute 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

First-Line Treatment for Acute Migraine

• NSAIDs are recommended as first-line therapy for most patients with mild to moderate migraine headaches, with options including aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 3
• Ensure patients are using appropriate dosages of NSAIDs or acetaminophen before considering them ineffective 1
• Acetaminophen alone has less efficacy than NSAIDs and should be used only in patients who cannot tolerate NSAIDs 2
• Combination analgesics containing caffeine can be effective for mild attacks 2

Second-Line Treatment for Acute Migraine

• If patients use an adequate dose of an NSAID or acetaminophen and still do not have sufficient pain relief, add a triptan to an NSAID, or to acetaminophen when NSAIDs are contraindicated or not tolerated 1, 2
• Triptans (such as sumatriptan, rizatriptan, naratriptan, zolmitriptan) are most effective when taken early in an attack while headache is still mild 2, 4
• If one triptan is ineffective, others might still provide relief due to individual response variations 2
• For patients with severe nausea or vomiting, consider non-oral triptans or adding an antiemetic such as metoclopramide or prochlorperazine 2, 3

Third-Line Treatment Options

• For patients who fail all available triptans or have contraindications to triptans, consider CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant), dihydroergotamine, or lasmiditan 1, 2
• Lasmiditan (ditan) should be considered only when patients do not tolerate or have inadequate response to all other pharmacologic treatments 1

Important Cautions

• Avoid opioids and butalbital-containing medications for the treatment of acute migraine headaches 1, 2
• Be aware of medication overuse headache, which can develop with frequent use of acute medications (≥15 days/month for NSAIDs, ≥10 days/month for triptans) 1, 2
• Sumatriptan is contraindicated in patients with coronary artery disease, Prinzmetal's variant angina, uncontrolled hypertension, history of stroke or TIA, and Wolff-Parkinson-White syndrome 4
• Monitor for serotonin syndrome when using triptans, particularly with concurrent use of SSRIs, SNRIs, TCAs, or MAO inhibitors 4

Preventive Treatment

• Consider preventive therapy for patients with: two or more attacks per month producing disability, contraindication to or failure of acute treatments, use of acute medication more than twice per week, or frequent episodic migraines 2, 5
• First-line preventive medications include beta-blockers (propranolol, metoprolol, timolol), topiramate, and divalproex sodium 5, 6
• Second-line preventive options include amitriptyline, venlafaxine, atenolol, and nadolol 6
• Other options with supporting evidence include candesartan, ACE inhibitors, and SSRIs 2, 6
• Complementary treatments with evidence of effectiveness include petasites, feverfew, magnesium citrate, coenzyme Q10, and riboflavin 5, 6

Lifestyle Modifications

• Counsel patients on important lifestyle modifications, including: 1, 2
  • Maintaining adequate hydration and regular meals
  • Ensuring sufficient and consistent sleep
  • Engaging in regular physical activity, preferably moderate to intense aerobic exercise
  • Managing stress with relaxation techniques or mindfulness practices
  • Pursuing weight loss if overweight or obese
• Identify and avoid individual migraine triggers 2
• Consider non-pharmacologic therapies such as relaxation training, biofeedback, and cognitive behavioral therapy 5, 6

Treatment Strategy Algorithm

1. Start with NSAIDs or acetaminophen at appropriate doses for mild to moderate attacks 1
2. If inadequate response, add a triptan to NSAID/acetaminophen 1
3. For patients who fail triptans, consider gepants, dihydroergotamine, or lasmiditan 1
4. Begin treatment as early as possible during an attack for maximum efficacy 2, 4
5. For frequent or debilitating migraines, add preventive therapy 1, 5