What is the first-line treatment for migraine?

First-Line Treatment for Migraine

For acute migraine treatment, NSAIDs are first-line therapy for mild to moderate attacks, while triptans are first-line for moderate to severe attacks. 1

Acute Treatment Algorithm

Mild to Moderate Migraine Attacks

• NSAIDs are recommended as first-line therapy, including ibuprofen (400-800mg), aspirin (900-1000mg), naproxen sodium, and diclofenac potassium 1, 2
• Acetaminophen plus aspirin plus caffeine combination is also effective as first-line therapy 2
• Acetaminophen alone has less efficacy and should only be used in patients who cannot tolerate NSAIDs 2

Moderate to Severe Migraine Attacks

• Triptans are first-line therapy for moderate to severe attacks 1, 3
• Sumatriptan is available in multiple formulations with recommended doses of 25mg, 50mg, or 100mg orally 4
• Doses of 50mg and 100mg may provide greater effect than 25mg, but 100mg may not provide greater effect than 50mg 4
• Other triptan options include rizatriptan, naratriptan, and zolmitriptan 1

Special Considerations

• For migraines with significant nausea or vomiting, use non-oral routes of administration (subcutaneous sumatriptan or nasal spray) 1, 2
• Add an antiemetic to treat nausea, even if vomiting is not present 2, 1
• Take medications early in the attack when headache is still mild for best results 2, 1
• Do not use triptans during the aura phase of a migraine attack 2

Medication Failures and Rescue Therapy

• If one triptan is ineffective, others might still provide relief 2
• When all other triptans have failed, sumatriptan by subcutaneous injection can be useful 2
• For headache recurrence within 48 hours, repeating triptan treatment or combining with fast-acting NSAIDs may help 2
• If all available triptans fail or are contraindicated, alternatives include ditans (lasmiditan) and gepants (ubrogepant, rimegepant) 2

Preventive Treatment Indications

• Consider preventive therapy for patients who experience two or more migraine attacks per month with disability lasting 3 or more days per month 5
• Patients using acute medications more than twice per week should be considered for preventive treatment to avoid medication overuse headache 5
• First-line preventive medications include propranolol (80-240 mg/day), timolol (20-30 mg/day), topiramate (100 mg/day), and candesartan 5

Common Pitfalls to Avoid

• Failing to recognize medication overuse headache from frequent use of acute medications (limit to no more than twice weekly) 5, 1
• Starting with too high a dose of preventive medication, leading to poor tolerability and discontinuation 5
• Inadequate duration of preventive trial (less than 2-3 months) 5
• Using triptans in patients with contraindications such as uncontrolled hypertension, basilar or hemiplegic migraine, or significant cardiovascular disease 1
• Using oral medications when gastroparesis accompanying migraine may impair absorption 1

Evidence Quality and Considerations

• The American Academy of Neurology, American College of Physicians, and American Academy of Family Physicians all support NSAIDs for mild-moderate attacks and triptans for moderate-severe attacks 2, 1
• Clinical trials demonstrate that sumatriptan at doses of 25mg, 50mg, and 100mg all provide significantly better headache response than placebo at 2 and 4 hours 4
• The stratified care approach (selecting treatment based on attack severity) is more effective than a stepped care approach 6