Treatment Options for Headaches
For acute migraine headaches, combination therapy with a triptan plus a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen is the most effective first-line treatment and should be initiated as early as possible after headache onset. 1
First-Line Treatment Options
Mild to Moderate Migraine Attacks
- NSAIDs are recommended as initial treatment for mild to moderate migraine attacks 1, 2:
- Ibuprofen 400-800 mg (oral)
- Naproxen sodium 275-550 mg (oral)
- Aspirin 650-1000 mg (oral)
- Acetaminophen 1000 mg is effective but has lower efficacy compared to NSAIDs 2, 3
- Combination analgesics containing caffeine (e.g., aspirin plus acetaminophen plus caffeine) are also effective for mild attacks 1, 2
Moderate to Severe Migraine Attacks
- Combination therapy with a triptan plus NSAID or acetaminophen is recommended for moderate to severe attacks 1, 2
- Triptans are most effective when taken early while headache is still mild 2
- If one triptan is ineffective, another within the same class may still provide relief 1, 2
Second-Line Treatment Options
- CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant for patients who don't respond to or cannot tolerate triptans plus NSAIDs 1, 2
- Dihydroergotamine (DHE) is suggested as an alternative when first-line treatments fail 1, 2
- Antiemetics like metoclopramide or prochlorperazine are recommended, particularly when migraine is accompanied by nausea/vomiting 1, 2
Third-Line Treatment Options
- Lasmiditan (ditan) is recommended for patients who don't respond to or cannot tolerate all other treatments 1, 2
- Intranasal lidocaine (limited evidence for efficacy) may be considered for patients who don't respond to other treatments 1
Special Considerations
Route of Administration
- For patients with severe nausea/vomiting, use non-oral routes of administration and add an antiemetic 1, 2
- Subcutaneous sumatriptan injection can be useful for patients who rapidly reach peak headache intensity or cannot take oral medications due to vomiting 1, 2
Medication Overuse Headache
- Monitor for medication overuse headache, which can occur with frequent use of acute medications (≥15 days/month for NSAIDs, ≥10 days/month for triptans) 1, 4, 5
Important Cautions and Contraindications
Medications to Avoid
- Avoid opioids and butalbital-containing medications for acute migraine treatment due to the risk of dependency, rebound headaches, and loss of efficacy 1, 2
Triptan Contraindications
- Triptans are contraindicated in patients with:
Potential Adverse Effects
- Serotonin syndrome may occur with triptans, particularly during co-administration with SSRIs, SNRIs, TCAs, and MAO inhibitors 4, 5
- Monitor for cerebrovascular events, as cerebral hemorrhage, subarachnoid hemorrhage, and stroke have occurred in patients treated with triptans 4, 5
- Significant elevation in blood pressure, including hypertensive crisis, has been reported with triptans 4, 5
Preventive Treatment
- Consider preventive therapy for patients with two or more attacks per month producing disability lasting 3+ days per month, contraindication to or failure of acute treatments, use of acute medication more than twice per week, or presence of uncommon migraine conditions 2
- Options include topiramate (with discussion of teratogenic effects), ACE inhibitors, ARBs, or SSRIs 2
Lifestyle Modifications
- Address predisposing factors such as poor sleep quality, poor physical fitness, or stress 2
- Maintain regular meals, stay well hydrated, and ensure sufficient sleep 2
- Engage in regular physical activity, preferably moderate to intense aerobic exercise 2
- Manage stress with relaxation techniques or mindfulness practices 2