Treatment Options for Migraine
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
Acute Treatment
First-Line Options
- NSAIDs are first-line treatments for mild to moderate migraine attacks, with proven efficacy options including acetylsalicylic acid (aspirin), ibuprofen, and diclofenac potassium 1, 2
- Paracetamol (acetaminophen) has less efficacy and should be used only in patients who cannot tolerate NSAIDs 1
- Treatment should be initiated as early as possible during an attack when pain is still mild 3
Second-Line Options
- Triptans should be offered to patients with moderate to severe attacks or when NSAIDs provide inadequate relief 1, 4
- If one triptan is ineffective, try another or a NSAID-triptan combination 3
- For rapidly escalating pain, consider non-oral triptans such as nasal or injectable formulations 3
- For patients with nausea/vomiting, use non-oral routes of administration or add an antiemetic 3, 1
Advanced Treatment Options
- For patients who fail triptans or have contraindications to them, options include CGRP antagonists (gepants), dihydroergotamine, or lasmiditan (ditan) 1, 4
- Avoid opioids and butalbital-containing analgesics due to risk of medication overuse headache 1, 4
Preventive Treatment
Indications for Prevention
- Consider preventive treatments in patients with frequent (≥2 attacks/month) or disabling headaches 1, 5
- Preventive therapy is also indicated when acute medications are ineffective, contraindicated, or overused 1, 5
First-Line Preventive Options
- Topiramate is a first-line option due to its efficacy and lower cost, but requires discussion of teratogenic effects with patients of childbearing potential 3, 1
- Beta-blockers (particularly propranolol) are effective preventive options 3, 5
- Amitriptyline is beneficial, especially for patients with comorbid depression or sleep disturbances 3, 6
Second-Line Preventive Options
- OnabotulinumtoxinA is specifically approved for chronic migraine 3, 6
- CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) are effective in patients who have failed at least two other preventive medications 3, 6
- Candesartan can be considered if first-line treatments are not tolerated or ineffective 1, 5
Managing Associated Symptoms and Complications
Medication Overuse Headache Prevention
- Limit acute medication use to prevent medication overuse headache: ≤15 days/month for NSAIDs, ≤10 days/month for triptans 1, 7
- Sumatriptan and other triptans can cause medication overuse headache if used too frequently 7
Comorbidity Management
- Identify and treat comorbid conditions such as anxiety, depression, sleep disturbances, and obesity 3, 6
- Select preventive medications that may address comorbidities: topiramate for patients with obesity, amitriptyline for depression or sleep disorders 6
Important Safety Considerations
Triptan Contraindications
- Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's variant angina, uncontrolled hypertension, and history of stroke or TIA 7
- Use caution with triptans in patients at risk for serotonin syndrome, especially when combined with SSRIs, SNRIs, TCAs, or MAO inhibitors 7
Lifestyle Modifications and Non-Pharmacological Approaches
- Advise patients on lifestyle factors, migraine triggers, and avoidance of acute medication overuse 3
- Maintain regular meals, stay well hydrated, and ensure sufficient sleep 1, 8
- Engage in regular physical activity, preferably moderate to intense aerobic exercise 1, 8
- Consider supplements such as riboflavin, coenzyme Q10, and magnesium for prevention 5, 8
- Stress management techniques including relaxation therapy and cognitive-behavioral therapy can be effective preventive strategies 1, 5