What is the best initial treatment for migraine?

Best Initial Treatment for Migraine

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are the best first-line therapy for initial treatment. 1, 2, 3

First-Line Treatment Options

• NSAIDs with proven efficacy include aspirin, ibuprofen, naproxen sodium, and the combination agent acetaminophen plus aspirin plus caffeine 1, 2
• Acetaminophen alone is not recommended as there is no evidence supporting its effectiveness for migraine 1, 2
• The acetaminophen-aspirin-caffeine combination has shown superior efficacy to sumatriptan in early treatment of migraine in some studies 4
• NSAIDs are particularly appropriate for mild to moderate migraines 3, 5

Second-Line Treatment Options

• For patients whose migraine attacks have not responded to NSAIDs, use migraine-specific agents (triptans, dihydroergotamine) 1, 2
• Triptans with good evidence for efficacy include oral naratriptan, rizatriptan, zolmitriptan, and sumatriptan 1, 6
• Sumatriptan is available in multiple doses (25mg, 50mg, 100mg), with 50mg and 100mg potentially providing greater effect than 25mg, though 100mg may not provide additional benefit over 50mg 6
• Triptans are particularly appropriate for moderate to severe migraines 3, 5

Route of Administration Considerations

• Select a non-oral route of administration for patients whose migraines present early with nausea or vomiting as a significant component 1, 2
• Options include subcutaneous sumatriptan or intranasal dihydroergotamine 1, 2
• Treat nausea and vomiting with an antiemetic, even when vomiting is not present 1, 7, 2
• Antiemetics not only treat nausea but also improve gastric motility which may be impaired during migraine attacks 7, 2

Important Contraindications and Precautions

• Triptans should be avoided in patients with vascular disease, uncontrolled hypertension, or hemiplegic migraine 8
• In patients with hepatic impairment, the maximum single dose of sumatriptan should not exceed 50mg 6
• Limit acute treatments to prevent medication overuse headache, which can occur when acute medications are used more than twice per week 1, 2
• If a migraine has not resolved within 2 hours after taking sumatriptan, a second dose may be administered, but the maximum daily dose should not exceed 200mg in a 24-hour period 6

Treatment Algorithm

1. For mild to moderate migraine:

   • Start with NSAIDs (ibuprofen, aspirin, naproxen sodium) or acetaminophen-aspirin-caffeine combination 1, 2, 3
   • If inadequate response within 2 hours, consider escalating to a triptan 6, 5

2. For moderate to severe migraine:

   • Consider starting with a triptan (sumatriptan, rizatriptan, zolmitriptan) 1, 6, 3
   • Sumatriptan 50mg is often sufficient; 100mg may not provide additional benefit 6

3. For migraine with significant nausea/vomiting:

   • Use non-oral route (subcutaneous, intranasal) 1, 2
   • Add an antiemetic such as metoclopramide or prochlorperazine 7, 2

4. For refractory migraine:

   • Consider combination therapy with a triptan plus NSAID 5
   • For status migrainosus (severe, continuous migraine lasting up to one week), systemic steroid therapy may be required 7

Special Considerations

• Avoid opioid-containing medications and barbiturates for acute migraine when possible 5, 8
• Over-the-counter medications are generally less expensive with fewer adverse effects compared to prescription medications, making them appropriate first-line options 9
• The effectiveness of early treatment (at the first sign of migraine) has been demonstrated in clinical trials 4, 5