What are the treatment options for migraines?

Treatment Options for Migraines

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

First-Line Treatment for Mild to Moderate Migraines

• NSAIDs are the first-line treatment for mild to moderate migraine attacks, with options including aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 3
• Acetaminophen can be used for mild attacks but has less efficacy than NSAIDs and should primarily be considered when NSAIDs are contraindicated 2, 4
• Combination analgesics containing acetaminophen, aspirin, and caffeine are effective for mild attacks 2, 5
• Begin treatment as early as possible during an attack for maximum efficacy 1, 2
• Consider increasing the dosage of an NSAID or acetaminophen (without exceeding the recommended maximum daily dose) if patients don't achieve sufficient pain relief 1

Second-Line Treatment for Moderate to Severe Migraines

• Triptans should be offered to patients for whom over-the-counter analgesics provide inadequate headache relief 1, 2
• Available triptans include sumatriptan, rizatriptan, almotriptan, eletriptan, frovatriptan, naratriptan, and zolmitriptan 1, 6
• If one triptan is ineffective, others may still provide relief 1, 2
• Combining a triptan with an NSAID or acetaminophen improves efficacy 1, 2
• For patients with severe nausea or vomiting, consider non-oral triptans (nasal spray, injection) and adding an antiemetic such as metoclopramide or prochlorperazine 3, 7

Third-Line Treatment for Refractory Migraines

• For patients who fail all available triptans or have contraindications to their use, consider CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant), dihydroergotamine, or the ditan lasmiditan 1, 2
• Lasmiditan should be considered only after all other pharmacologic treatments have failed 1

Important Cautions and Considerations

• Avoid opioids and butalbital-containing medications for migraine treatment 1, 3
• Be aware of medication overuse headache, which can occur when acute treatments are used too frequently (≥15 days/month for NSAIDs, ≥10 days/month for triptans) 1, 2
• Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's variant angina, Wolff-Parkinson-White syndrome, history of stroke or TIA, and uncontrolled hypertension 8
• Monitor for serotonin syndrome when triptans are used concurrently with SSRIs, SNRIs, TCAs, or MAO inhibitors 8

Preventive Treatment

• Consider preventive therapy for patients with frequent episodic migraine (2+ attacks per month), significant disability, contraindication to or failure of acute treatments, or medication overuse 2, 9
• Erenumab (Aimovig) is FDA-approved for the preventive treatment of migraine in adults 10
• Clinical trials show erenumab significantly reduces monthly migraine days compared to placebo in both episodic and chronic migraine patients 10
• Other preventive options include topiramate, beta-blockers (propranolol, timolol), antidepressants (amitriptyline), and anticonvulsants (divalproex sodium/sodium valproate) 2, 9

Lifestyle Modifications

• Counsel patients on important lifestyle modifications, including: 1, 2
  • Maintaining adequate hydration and regular meals
  • Ensuring sufficient and consistent sleep
  • Engaging in regular physical activity, preferably moderate to intense aerobic exercise
  • Managing stress with relaxation techniques or mindfulness practices
  • Pursuing weight loss if overweight or obese