What are the treatment options for migraine?

Treatment of Migraine

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

Acute Treatment Options

First-Line Treatment

• For mild to moderate migraine attacks, use NSAIDs such as ibuprofen (400-800 mg), naproxen sodium (275-550 mg), aspirin (650-1000 mg), or diclofenac potassium 1, 2
• Combination analgesics containing caffeine (e.g., aspirin plus acetaminophen plus caffeine) are effective for mild attacks 1, 2
• Paracetamol (acetaminophen) has less efficacy and should be used only in patients who cannot tolerate NSAIDs 1
• For moderate to severe attacks, triptans (sumatriptan, rizatriptan, etc.) are recommended as first-line treatment 2, 3
• Combination therapy with a triptan plus an NSAID or acetaminophen is most effective and should be initiated as early as possible while headache is still mild 1, 2

Second-Line Treatment

• For patients who fail all available triptans or have contraindications to triptans, options include CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant 1, 2
• Dihydroergotamine (DHE) is an alternative when first-line treatments fail 2, 4
• Lasmiditan (ditan) is recommended for patients who don't respond to other treatments 2

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 Cautions

• Avoid opioids and butalbital-containing analgesics for migraine treatment due to risk of dependency, rebound headaches, and loss of efficacy 1, 2, 4
• Limit acute medication use to prevent medication overuse headache (≤15 days/month for NSAIDs, ≤10 days/month for triptans) 1, 2
• Triptans are contraindicated in patients with ischemic or vasospastic coronary artery disease 3
• Triptans may cause coronary artery vasospasm (Prinzmetal's Angina), even in patients without a history of CAD 3
• Serotonin syndrome may occur with triptans, particularly during coadministration with SSRIs, SNRIs, TCAs, and MAO inhibitors 3

Preventive Treatment

Indications for Preventive Therapy

• Consider preventive therapy for patients with: two or more attacks per month producing disability lasting 3+ days per month; contraindication to or failure of acute treatments; use of acute medication more than twice per week; or presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 1

Preventive Treatment Options

• First-line options include topiramate, beta-blockers, and tricyclic antidepressants 1, 5
• The American Academy of Neurology recommends topiramate as an effective option, but requires discussion of teratogenic effects with patients of childbearing potential 1
• ACE inhibitors, ARBs, or SSRIs can be considered if first-line treatments are not tolerated or result in inadequate response 1
• Start preventive medications at a low dose and gradually increase until desired outcomes are achieved 1
• Monitor treatment using a headache diary to determine efficacy, 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

Lifestyle Modifications

• Address predisposing factors such as poor sleep quality, poor physical fitness, or stress 1, 4
• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 1, 4
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1
• Manage stress with relaxation techniques or mindfulness practices 1, 4

Special Considerations

• If one triptan is ineffective, another within the same class may still provide relief 1, 3
• Subcutaneous sumatriptan injection can be useful for patients who rapidly reach peak headache intensity or cannot take oral medications due to vomiting 1, 2
• Triptans are most effective when taken early in an attack while headache is still mild 1, 6
• For pediatric patients (6-17 years), weight-based dosing of triptans is recommended, with efficacy demonstrated in clinical trials 3