Treatment of Migraines: Prescription Medications and Lifestyle Modifications
For most migraine sufferers, first-line therapy should be NSAIDs (such as aspirin, ibuprofen, naproxen sodium) or combination therapy with a triptan plus an NSAID or acetaminophen. 1, 2
Acute Treatment Algorithm
First-Line Treatment
- Start with NSAIDs with proven efficacy: aspirin, ibuprofen, naproxen sodium, or combination of acetaminophen plus aspirin plus caffeine for mild to moderate attacks 1, 2
- Administer early in the headache phase for maximum effectiveness 1, 2
- There is no evidence supporting the use of acetaminophen alone 1
Second-Line Treatment
- Use triptans for moderate to severe attacks or when NSAIDs provide inadequate relief 1
- Consider combination therapy (triptan with an NSAID or acetaminophen) to improve efficacy 1, 3
- Oral triptans with proven efficacy include sumatriptan, naratriptan, rizatriptan, and zolmitriptan 1, 4
- For patients with significant nausea/vomiting, use non-oral routes: subcutaneous sumatriptan, nasal spray formulations, or oral disintegrating tablets 1, 5
Third-Line Treatment
- For patients who don't tolerate or have inadequate response to combination therapy, consider CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) 1, 6
- Consider the ditan lasmiditan only for patients who don't respond to all other treatments 1
Important Cautions
- Do NOT use opioids or butalbital for acute migraine treatment 1, 2, 6
- Be aware of medication overuse headache risk (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1, 4
- Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, and history of stroke or TIA 4
Preventive Treatment Considerations
When to Consider Prevention
- Two or more attacks per month that produce 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, 2
- Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura, migrainous infarction) 1
First-Line Preventive Options
- Beta-blockers: propranolol (80-240 mg/day), timolol (20-30 mg/day) 1, 2
- Tricyclic antidepressants: amitriptyline (30-150 mg/day) 1, 2
- Anticonvulsants: divalproex sodium, sodium valproate 1, 2
Lifestyle Modifications
- Maintain regular hydration, meals, and consistent sleep patterns 1
- Engage in regular physical activity, preferably moderate to intense aerobic exercise 1
- Manage stress with relaxation techniques or mindfulness practices 1
- Pursue weight loss if overweight or obese 1
- Identify and avoid personal migraine triggers 1
Special Considerations
- For pregnant or breastfeeding patients, discuss adverse effects of medications during pregnancy and lactation 1
- For patients with early nausea/vomiting during attacks, use antiemetics alongside migraine treatment 1
- Counsel patients to begin treatment as soon as possible after migraine onset 1, 2
- Consider cost when prescribing medications - triptans and newer agents (gepants, ditans) may be expensive 1, 3, 6
Treatment Efficacy
- Sumatriptan 50mg and 100mg provide similar efficacy with headache relief at 2 hours in approximately 50-62% of patients compared to 17-27% with placebo 4, 7
- The 50mg dose of sumatriptan may offer the best ratio of efficacy to tolerability 7, 8
- Combination therapy with a triptan plus NSAID is more effective than either medication alone 1, 3