What are the treatments for migraines?

Treatment of Migraines

For acute episodic migraine treatment, begin with NSAIDs or acetaminophen, and if insufficient, add a triptan; avoid opioids and butalbital completely. 1

First-Line Treatments for Acute Migraine

Mild to Moderate Attacks

• Start with NSAIDs (aspirin, celecoxib, diclofenac, ibuprofen, or naproxen) or acetaminophen at appropriate dosages 1
• Consider combination therapy of an NSAID plus acetaminophen for enhanced efficacy 1
• Ensure adequate dosing before concluding treatment failure - consider increasing the dose without exceeding maximum daily recommendations 1

Moderate to Severe Attacks

• If NSAIDs/acetaminophen provide insufficient relief, add a triptan (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan) 1
• Triptans work through 5-HT1B/1D receptor agonism, causing cranial vessel constriction and inhibiting pro-inflammatory neuropeptide release 2
• Begin treatment as early as possible after migraine onset for best results 1, 3
• For patients with severe nausea/vomiting, consider non-oral triptan formulations (nasal, injectable) along with an antiemetic 1, 3

Second-Line Treatments

• For patients who don't respond to or cannot tolerate first-line options, consider CGRP antagonists (gepants: rimegepant, ubrogepant, zavegepant) or dihydroergotamine 1
• The ditan lasmiditan may be used when patients don't respond to all other pharmacologic treatments 1
• For status migrainosus (severe, continuous migraine lasting up to one week), systemic corticosteroid therapy is the treatment of choice 4

Treatment Algorithm

1. Initial Assessment: Determine migraine severity (mild, moderate, severe)

   • For mild-moderate: Start with NSAIDs or acetaminophen 1
   • For moderate-severe: Consider starting with combination therapy (NSAID + triptan) 1

2. If Initial Treatment Fails:

   • Ensure adequate dosing of current medication 1
   • Add a triptan to NSAID/acetaminophen if not already using one 1
   • Consider switching within the same drug class (different NSAID or different triptan) 1

3. For Refractory Cases:

   • Consider CGRP antagonists or dihydroergotamine 1
   • Lasmiditan as last pharmacologic option 1
   • For status migrainosus: IV corticosteroids plus antiemetics 4

Special Considerations

Pregnancy and Lactation

• Acetaminophen is the safest first-line option during pregnancy 5
• NSAIDs like ibuprofen can be used only during the second trimester 5
• Sumatriptan may be used sporadically under specialist supervision when other treatments fail 5

Medication Overuse Headache

• Be vigilant about medication overuse headache, which occurs when acute medications are used too frequently (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
• This complication requires limiting acute medication use and may necessitate preventive therapy 1

Preventive Treatment

• Consider preventive medications when episodic migraines occur frequently or acute treatments don't provide adequate response 1
• During pregnancy, propranolol has the best safety profile for prevention if needed 5

Important Cautions

• Never use opioids or butalbital for acute migraine treatment due to risks of dependency and medication overuse headache 1, 4
• Triptans are contraindicated in patients with cardiovascular disease due to their vasoconstrictive properties 3, 6
• Medication overuse can transform episodic migraine into chronic daily headache, one of the major avoidable causes of headache disability 1, 7

Non-Pharmacological Management

• Lifestyle modifications are important adjuncts to pharmacological treatment 1
• Recommend staying well hydrated, maintaining regular meals and sleep patterns, engaging in regular physical activity, and managing stress 1
• Identify and avoid individual migraine triggers 1, 5

Efficacy Considerations

• Triptans show high efficacy with rizatriptan demonstrating pain freedom in 33% of pediatric patients at 2 hours compared to 24% with placebo 6
• Combination therapy (triptan plus NSAID) is more effective than monotherapy with either agent 1, 3
• The choice of specific NSAID or triptan should consider route of administration preferences and cost 1