What are the treatment options for migraine?

Treatment Options for Migraine

For acute migraine treatment, start with NSAIDs for mild to moderate attacks and progress to triptans or combination therapy for moderate to severe attacks. 1, 2

First-Line Treatment Approach

• NSAIDs are recommended as first-line therapy for most patients with mild to moderate migraine attacks, with options including aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 2
• Ensure patients are using appropriate dosages of NSAIDs or acetaminophen before considering them ineffective - consider increasing the dosage without exceeding the recommended maximum daily dose 1
• Acetaminophen has less efficacy than NSAIDs and should be used only in patients who are intolerant of NSAIDs 2
• Combination analgesics containing caffeine can be effective for mild attacks 2
• Treatment should begin as early as possible during an attack for maximum efficacy 2, 3

Second-Line Treatment Approach

• If patients use an adequate dose of an NSAID or acetaminophen and still do not have sufficient pain relief, add a triptan to an NSAID, or to acetaminophen when NSAIDs are contraindicated or not tolerated 1, 2
• Triptans (sumatriptan, rizatriptan, naratriptan, zolmitriptan, almotriptan, eletriptan, frovatriptan) should be offered to patients for whom over-the-counter analgesics provide inadequate headache relief 1, 2
• Triptans are most effective when taken early in an attack while headache is still mild 2, 3
• If one triptan is ineffective, others might still provide relief - choice of specific triptan should be based on individualized decision making, considering factors like route of administration and cost 1, 2
• Combining a triptan with an NSAID or acetaminophen improves efficacy 1, 2

Managing Associated Symptoms

• For patients with severe nausea or vomiting, consider non-oral routes of administration for triptans and add an antiemetic 2, 4
• Antiemetics like metoclopramide or prochlorperazine can treat accompanying nausea and improve gastric motility 2, 4

Advanced Treatment Options

• For patients who fail all available triptans or have contraindications to triptans, options include CGRP antagonists (gepants) like rimegepant, ubrogepant, or zavegepant; dihydroergotamine (DHE); or lasmiditan (ditan) 1, 2
• Consider lasmiditan only for patients who do not tolerate or have inadequate response to all other pharmacologic treatments 1

Important Cautions and Considerations

• Avoid opioids and butalbital-containing analgesics for migraine treatment 1, 2
• Be aware of medication overuse headache, which can develop with frequent use of acute medications (≥15 days/month for NSAIDs, ≥10 days/month for triptans) 1, 2
• Sumatriptan is contraindicated in patients with coronary artery disease, Prinzmetal's variant angina, Wolff-Parkinson-White syndrome, history of stroke or TIA, and uncontrolled hypertension 3
• Serotonin syndrome may occur with sumatriptan, particularly during co-administration with SSRIs, SNRIs, TCAs, and MAO inhibitors 3

Preventive Treatment

• Consider preventive therapy for patients with frequent episodic migraine attacks (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 2
• If the episodic migraine occurs frequently or treatment does not provide an adequate response, the addition of preventive medications may be warranted 1

Lifestyle Modifications

• Address predisposing factors such as poor sleep quality, poor physical fitness, or stress 2
• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 1, 2
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1, 2
• Manage stress with relaxation techniques or mindfulness practices 1, 2
• Pursue weight loss for those who are overweight or obese 1