What is the best treatment for migraines?

Best Treatment for Migraines

For most migraine patients, a stepped care approach starting with NSAIDs for mild to moderate attacks and triptans for moderate to severe attacks provides the best outcomes for reducing pain, disability, and improving quality of life. 1, 2

Acute Treatment Algorithm

First-Line Options

• NSAIDs with proven efficacy (aspirin, ibuprofen, diclofenac potassium) should be used first for mild to moderate migraine attacks 1, 2
• Paracetamol/acetaminophen has less efficacy than NSAIDs and should only be used in patients who cannot tolerate NSAIDs 1
• Triptans (sumatriptan, rizatriptan, zolmitriptan, eletriptan, almotriptan) are first-line for moderate to severe attacks or when NSAIDs fail 1, 2
• Treat acute migraine early in the attack for best results 1

For Attacks with Significant Nausea/Vomiting

• Use non-oral routes of administration such as subcutaneous or nasal spray triptans 1, 2
• Add antiemetics like metoclopramide or prochlorperazine to treat nausea and improve gastric motility 3, 2

For Refractory Attacks

• If one triptan is ineffective, try another triptan or a NSAID-triptan combination 1
• For rapidly escalating pain, consider non-oral triptans (subcutaneous sumatriptan) 1, 4
• For status migrainosus (prolonged, severe migraine), systemic corticosteroids are the treatment of choice 3

Preventive Treatment

Preventive therapy should be considered in these circumstances:

• Frequent migraines (≥4 headaches/month or ≥8 headache days/month) 5, 6
• Debilitating headaches despite acute treatment 5, 7
• Medication overuse headaches 5, 6
• Patient preference 7

First-Line Preventive Options

• Beta-blockers: propranolol, metoprolol, timolol 1, 5
• Anticonvulsants: topiramate, divalproex sodium 1, 5
• Amitriptyline combined with cognitive behavioral therapy 1, 5

Second-Line Preventive Options

• Venlafaxine, atenolol, nadolol 1, 5
• Calcium channel blockers 1, 5
• OnabotulinumtoxinA (FDA approved for chronic migraine) 1

Special Considerations

Non-Pharmacologic Approaches

• Identify and manage environmental, dietary, and behavioral triggers 1
• Relaxation training, thermal biofeedback, cognitive behavioral therapy have good evidence for migraine prevention 5
• Complementary treatments with evidence of efficacy include magnesium, riboflavin, petasites, and feverfew 5

Medication Overuse

• Limit acute medication use to avoid medication overuse headache 1, 6
• For NSAIDs: limit to ≤15 days/month 1
• For triptans: limit to ≤10 days/month 1

Important Cautions

• Triptans are contraindicated in patients with cardiovascular disease 2
• Topiramate and valproate have teratogenic effects; advise effective birth control and folate supplementation in women of childbearing potential 1
• Opioids should be limited due to risk of dependency, rebound headaches, and eventual loss of efficacy 3
• Monitor elderly patients on triptans more closely due to increased half-life and potential for greater blood pressure elevations 4

Efficacy Considerations

• In clinical trials, eletriptan 40mg showed headache response rates of 53.9-65.0% at 2 hours compared to 19.0-39.5% for placebo 4
• Early intervention during mild pain phase significantly improves outcomes 1, 8
• Preventive medications can reduce migraine frequency by 50% or more in approximately half of patients 5, 6

By following this stepped care approach and considering both acute and preventive strategies, most migraine patients can achieve significant improvement in their quality of life and reduction in migraine-related disability.