From the Guidelines
Migraines should be treated with a combination of acute and preventive therapies, prioritizing medications such as ibuprofen, naproxen, and triptans for acute attacks, and beta blockers, topiramate, or candesartan for prevention, as these have shown the most consistent evidence for reducing morbidity, mortality, and improving quality of life 1.
Causes of Migraines
Migraines are complex and multifactorial, involving abnormal brain activity, nerve signals, blood vessels, and chemicals like serotonin.
- Genetic predisposition
- Hormonal changes
- Environmental factors, such as stress, certain foods, and irregular sleep patterns
- Neurological factors, including nerve signal transmission and blood vessel dilation
Acute Treatment of Migraines
For acute migraine treatment, the following medications are recommended:
- Over-the-counter medications like ibuprofen (400-600mg) or naproxen (500-550mg) at the first sign of symptoms 1
- Prescription triptans, such as sumatriptan (50-100mg orally), which can provide relief within 2 hours if initial treatments are ineffective 1
Preventive Treatment of Migraines
For frequent migraines (more than 2 days per month), preventive medications may be necessary, including:
- Beta blockers, such as propranolol (80-160mg daily), atenolol, bisoprolol, or metoprolol 1
- Topiramate (50-100mg daily) 1
- Candesartan 1
- Amitriptyline (10-50mg at bedtime), although this is considered a second-line medication 1
Lifestyle Modifications
Lifestyle modifications are equally important for managing migraines:
- Identify and avoid personal triggers, such as certain foods, stress, and irregular sleep patterns
- Maintain consistent sleep patterns
- Stay hydrated
- Practice stress management techniques, such as meditation
- Keep a migraine diary to track triggers and medication effectiveness
From the FDA Drug Label
Sumatriptan binds with high affinity to human cloned 5-HT1B/1D receptors Sumatriptan presumably exerts its therapeutic effects in the treatment of migraine headache through agonist effects at the 5-HT1B/1D receptors on intracranial blood vessels and sensory nerves of the trigeminal system, which result in cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release.
The causes of migraines are not directly addressed in the provided drug labels. The treatments of migraines mentioned include sumatriptan, which is believed to work through agonist effects at the 5-HT1B/1D receptors on intracranial blood vessels and sensory nerves of the trigeminal system 2. Key points to consider when treating migraines with sumatriptan include:
- Performing a cardiovascular evaluation in triptan-naive patients who have multiple cardiovascular risk factors prior to receiving sumatriptan tablets
- Considering administering the first dose of sumatriptan tablets in a medically supervised setting and performing an electrocardiogram (ECG) immediately following administration of sumatriptan tablets for patients with multiple cardiovascular risk factors who have a negative cardiovascular evaluation
- Monitoring blood pressure in patients treated with sumatriptan, as significant elevation in blood pressure, including hypertensive crisis, has been reported in patients with and without a history of hypertension 2.
From the Research
Causes of Migraines
- Migraines are a complex condition with various risk factors, including age, sex, and genetics 3
- The exact causes of migraines are not fully understood, but they are thought to involve a combination of neurological, vascular, and environmental factors
Treatments for Migraines
- Acute treatment options for migraines include:
- Migraine-specific medications such as triptans, ergot derivatives, and calcitonin gene-related peptide receptor antagonists 4, 5, 3
- Nonspecific medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and antiemetic drugs 6, 7
- Neuromodulation devices, which offer a nonpharmacologic option for acute treatment 4, 5
- The goal of acute treatment is to stop the pain and associated symptoms of the migraine attack and return the patient to normal function 3
- Effective treatment of migraines requires a personalized approach, taking into account the patient's medical history, comorbidities, and preferences, as well as published clinical evidence 3
Acute Treatment Options
- Triptans, such as sumatriptan, zolmitriptan, and rizatriptan, are effective for moderate to severe migraines, but may have adverse events 6
- NSAIDs, such as aspirin, ibuprofen, and naproxen, are effective for mild to moderate migraines 7
- Calcitonin gene-related peptide receptor antagonists, such as gepants, are a new class of acute treatment options that have not been associated with vasospasm or increased cardiovascular risk 4
- Neuromodulation devices, such as remote electrical neuromodulation, offer a nonpharmacologic option for acute treatment 4, 5
Treatment Guidelines
- The American Headache Society (AHS) and the Taiwan Headache Society have published treatment guidelines for acute migraine attacks, which recommend a stratified care approach based on the severity of the attack 7
- The guidelines recommend using migraine-specific medications, such as triptans, and nonspecific medications, such as NSAIDs, as first-line treatments for acute migraine attacks 7
- Antiemetics can be used as a supplement to alleviate nausea and vomiting, and parenteral steroid and fluid supply are recommended for status migrainosus 7