What are the treatment options for migraines?

Treatment Options for Migraines

For migraine treatment, a stepped care approach should be used, starting with NSAIDs for mild to moderate attacks and progressing to triptans or combination therapy for moderate to severe attacks. 1, 2

Acute Treatment

First-Line Options

• NSAIDs are recommended as first-line therapy for mild to moderate migraine attacks, with proven efficacy for acetylsalicylic acid (aspirin), ibuprofen, naproxen sodium, and diclofenac potassium 1, 2
• Combination analgesics containing caffeine (acetaminophen plus aspirin plus caffeine) can be effective for mild attacks 1, 2
• Paracetamol (acetaminophen) has less efficacy and should be used only in patients who are intolerant of NSAIDs 1
• Treatment should begin as early as possible during an attack for maximum efficacy 2

Second-Line Options

• Triptans 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 1
• If one triptan is ineffective, others might still provide relief 1
• Non-oral triptans (nasal spray, subcutaneous injection) should be considered for patients with significant nausea or vomiting 1, 2
• Important caution: Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's variant angina, Wolff-Parkinson-White syndrome, history of stroke/TIA, and uncontrolled hypertension 3

Third-Line and Advanced Options

• For patients who fail all available triptans or have contraindications to triptans, options include:
  • CGRP antagonists (gepants) like rimegepant, ubrogepant, or zavegepant 1, 2
  • Dihydroergotamine (DHE) 1, 2
  • Lasmiditan (ditan) 1

Managing Associated Symptoms

• Consider antiemetics like metoclopramide or prochlorperazine to treat accompanying nausea and improve gastric motility 1, 2
• Use non-oral routes of administration for patients with migraine accompanied by significant nausea/vomiting 1, 2

Treatment Cautions

• Avoid opioids and butalbital-containing analgesics for migraine treatment due to questionable efficacy, adverse effects, and risk of dependency 1, 2, 4
• Limit acute medication use to prevent medication overuse headache (≤15 days/month for NSAIDs, ≤10 days/month for triptans) 1, 2
• Serotonin syndrome may occur with triptans, particularly during co-administration with SSRIs, SNRIs, TCAs, and MAO inhibitors 3

Preventive Treatment

Indications for Prevention

• Consider preventive therapy for patients with:
  • Two or more attacks per month producing disability lasting 3+ days per month 1
  • Contraindication to or failure of acute treatments 1
  • Use of acute medication more than twice per week 1
  • Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 1

Preventive Medication Options

• FDA-approved preventive treatments include:
  • Erenumab (AIMOVIG) for preventive treatment of migraine in adults 5
  • Other options include topiramate, propranolol, timolol, amitriptyline, and divalproex sodium/sodium valproate 1, 2
• For patients with inadequate response to first-line preventives, consider ACE inhibitors, ARBs, or SSRIs 1
• Start preventive medications at a low dose and gradually increase until desired outcomes are achieved 1
• Monitor treatment efficacy using a headache diary and switch preventive treatment if an adequate response is not achieved during a reasonable trial period 1

Lifestyle Modifications

• Address predisposing factors such as poor sleep quality, poor physical fitness, or stress 1, 2, 4
• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 1, 2, 4
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1, 2
• Manage stress with relaxation techniques or mindfulness practices 1, 2
• Consider weight loss if overweight or obese 2, 4

Combination Therapy

• Combining a triptan with an NSAID or acetaminophen improves efficacy compared to either medication alone 1, 2
• Begin treatment as soon as possible after migraine onset using combination therapy for better results 1