Migraine Treatment Options

For acute migraine treatment, start with acetaminophen for mild to moderate attacks, and add a triptan if there is inadequate response. 1

First-Line Treatment

The American College of Physicians recommends acetaminophen as first-line therapy for mild to moderate acute episodic migraine headaches in outpatient settings 1
NSAIDs with proven efficacy include acetylsalicylic acid (aspirin), ibuprofen, naproxen sodium, and diclofenac potassium 2, 3
Treatment should begin as early as possible during an attack for maximum efficacy 2, 3
Combination analgesics containing caffeine can be effective for mild attacks 2

For patients with moderate to severe acute episodic migraine headache who do not respond adequately to acetaminophen, add a triptan to acetaminophen 1, 2
Triptans are most effective when taken early in an attack while headache is still mild 2, 4
If one triptan is ineffective, others may still provide relief 2
Sumatriptan has demonstrated efficacy in clinical trials with 50-62% of patients achieving headache response at 2 hours compared to 17-27% with placebo 4

Combining a triptan with an NSAID or acetaminophen improves efficacy 2, 3
Patients should begin treatment as soon as possible after migraine onset 2
For patients with severe nausea or vomiting, consider non-oral routes of administration or adding an antiemetic such as metoclopramide or prochlorperazine 2, 3

For patients who fail all available triptans or have contraindications to triptans, options include CGRP antagonists (gepants), ditans (5-HT1F agonists), or dihydroergotamine (DHE) 2, 3
Subcutaneous sumatriptan injection can be useful for patients who cannot take oral triptans due to vomiting 2

Avoid opioids and butalbital-containing analgesics for migraine treatment 2, 3
Limit acute medication use to prevent medication overuse headache (≤15 days/month for NSAIDs, ≤10 days/month for triptans) 2, 3
Triptans are contraindicated in patients with:
- Coronary artery disease or Prinzmetal's variant angina 4
- History of stroke or TIA 4
- Uncontrolled hypertension 4
- Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders 4
Monitor for serotonin syndrome when triptans are used with SSRIs, SNRIs, TCAs, or MAO inhibitors 4

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
- Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 2
Effective preventive options include beta blockers, topiramate, or candesartan as first-line medications 2, 5

Address predisposing factors such as poor sleep quality, poor physical fitness, or stress 2
Maintain regular meals, stay well hydrated, and ensure sufficient sleep 2, 5
Engage in regular physical activity, preferably moderate to intense aerobic exercise 2
Manage stress with relaxation techniques or mindfulness practices 2