What are the treatment options for migraines?

Migraine Treatment Options

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

Acute Treatment Algorithm

First-Line Treatment

• NSAIDs are recommended as first-line therapy for most patients with mild to moderate migraine headaches, with effective options including aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 2
• Combination analgesics containing caffeine (acetaminophen plus aspirin plus caffeine) are effective for mild attacks, but acetaminophen alone has less efficacy 1, 2
• Treatment should begin as early as possible during an attack for maximum efficacy 1, 2

Second-Line Treatment

• Triptans should be offered to patients for whom over-the-counter analgesics provide inadequate headache relief 1, 2
• Triptans are most effective when taken early in an attack while headache is still mild 1, 2
• If one triptan is ineffective, others might still provide relief 1
• Important triptan contraindications include:
  • Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders 3, 4
  • Coronary artery disease or Prinzmetal's variant angina 3, 4
  • History of stroke or TIA 3, 4
  • Uncontrolled hypertension 3, 4

Third-Line Treatment

• For patients who fail all available triptans or have contraindications to triptans, options include:
  • CGRP antagonists (gepants) like rimegepant, ubrogepant, or zavegepant 1, 2
  • Dihydroergotamine (DHE) 1, 2
  • Lasmiditan (ditan) 1

Combination Therapy

• Combining a triptan with an NSAID or acetaminophen improves efficacy 1, 2
• Patients should begin treatment as soon as possible after migraine onset using combination therapy when appropriate 1

Managing Associated Symptoms

• Use non-oral routes of administration for patients with migraine accompanied by nausea/vomiting 1, 2
• Consider antiemetics like metoclopramide or prochlorperazine to treat accompanying nausea and improve gastric motility 1, 2

Important Treatment Cautions

• Avoid opioids and butalbital-containing analgesics for migraine treatment 1, 2
• Limit acute medication use to prevent medication overuse headache:
  • ≤15 days/month for NSAIDs 1, 2
  • ≤10 days/month for triptans 1, 2
• Monitor for serotonin syndrome when triptans are used with SSRIs, SNRIs, TCAs, or MAO inhibitors 3, 4
• Watch for potential cardiovascular side effects with triptans, including chest pain/tightness and blood pressure elevation 3, 4

Preventive Treatment

When to Consider Prevention

• Two or more attacks per month producing disability lasting 3+ days per month 1
• Contraindication to or failure of acute treatments 1
• Use of acute medication more than twice per week 1
• Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 1

First-Line Preventive Options

• Beta-blockers (propranolol, timolol, metoprolol) 1, 2, 5
• Anticonvulsants (topiramate, divalproex sodium/sodium valproate) 1, 5
• Note: Topiramate requires discussion of teratogenic effects with patients of childbearing potential 1

Second-Line Preventive Options

• Tricyclic antidepressants (amitriptyline) 1, 5
• SNRIs (venlafaxine) 1
• ACE inhibitors or ARBs (candesartan) 1, 6
• Calcium channel blockers 5

Monitoring Preventive Treatment

• Use a headache diary to determine treatment efficacy 1
• Identify analgesic overuse and follow up on migraine progression 1
• Switch preventive treatment if an adequate response is not achieved during a reasonable trial period 1
• Start preventive medications at a low dose and gradually increase until desired outcomes are achieved 1

Lifestyle Modifications

• Address predisposing factors such as poor sleep quality, poor physical fitness, or stress 1, 2, 6
• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 1, 2, 6
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1, 2
• Manage stress with relaxation techniques or mindfulness practices 1, 2

Complementary Treatments

• Supplements with evidence for effectiveness include petasites, feverfew, magnesium, and riboflavin 5
• Non-pharmacologic therapies such as relaxation training, biofeedback, and cognitive behavior therapy can be effective 5