What are the treatment options for migraines?

Treatment Options for Migraines

For acute, episodic, moderate to severe migraine headaches, the most effective first-line treatment is combination therapy with a triptan plus an NSAID or acetaminophen, which should be initiated as early as possible after headache onset. 1, 2

Stepped Care Approach for Acute Treatment

• Start with NSAIDs or acetaminophen for mild to moderate attacks:

  • NSAIDs with proven efficacy: aspirin (650-1000 mg), ibuprofen (400-800 mg), diclofenac, naproxen (275-550 mg) 1, 2
  • Acetaminophen has less efficacy and should be used only when NSAIDs are contraindicated or not tolerated 2
  • Ensure appropriate dosing of NSAIDs or acetaminophen before concluding they are ineffective 1

• For moderate to severe attacks or when NSAIDs/acetaminophen are insufficient:

  • Add a triptan (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan) 1, 2
  • Triptans are most effective when taken early while headache is still mild 2
  • If one triptan is ineffective, another within the same class may still provide relief 1, 2

• For patients with severe nausea/vomiting:

  • Use non-oral routes of administration (e.g., subcutaneous sumatriptan injection) 2, 3
  • Add an antiemetic like metoclopramide or prochlorperazine 2, 3

Advanced Treatment Options

• For patients who fail triptans or have contraindications:
  • CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 1, 3
  • Dihydroergotamine (DHE) 1, 3
  • Lasmiditan (ditan) - consider as last option when other treatments fail 1, 3

Important Cautions

• Avoid opioids and butalbital-containing medications for migraine treatment due to risk of dependency, rebound headaches, and loss of efficacy 1, 3
• Monitor for medication overuse headache, which can occur with frequent use of acute medications (≥15 days/month for NSAIDs, ≥10 days/month for triptans) 1, 2
• Be aware of potential serious side effects with triptans, including vasospastic reactions, chest/throat/neck/jaw pain, cerebrovascular events, and serotonin syndrome 4

Preventive Treatment

• Consider preventive therapy for patients with:

  • Two or more attacks per month producing disability lasting 3+ days per month 2, 5
  • Contraindication to or failure of acute treatments 2, 6
  • Use of acute medication more than twice per week 2, 6
  • Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 2

• First-line preventive medications:

  • Beta-blockers (propranolol, metoprolol) 6, 7
  • Topiramate 2, 7
  • Divalproex/valproate 6, 7
  • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) for patients who have failed other preventives 8, 7
  • OnabotulinumtoxinA specifically for chronic migraine 9, 7

• Second-line preventive medications:

  • Amitriptyline (especially with comorbid depression or sleep disorders) 9, 7
  • Venlafaxine 7
  • ACE inhibitors or ARBs 2

Lifestyle Modifications

• Identify and manage migraine triggers: alcohol, anxiety, dehydration, excessive caffeine, eye strain, hunger, sleep deprivation, and stress 10, 11
• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 1, 2
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1, 11
• Manage stress with relaxation techniques or mindfulness practices 1, 10
• Consider weight loss for patients who are overweight or obese 1, 11
• Monitor treatment efficacy using a headache diary 2, 9

Complementary Approaches

• Consider evidence-based supplements: riboflavin, coenzyme Q10, and magnesium 10, 7
• Acupuncture may provide benefit for some patients 10, 7
• Cognitive behavioral therapy can help with trigger management and stress reduction 10, 7