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

Acute Treatment Options

First-Line Treatments

• 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 2, 1, 3
• Acetaminophen (1000 mg) can be used for tension-type headache but has less efficacy for migraine and should be used only in patients who are intolerant of NSAIDs 2, 1
• Combination analgesics containing caffeine (aspirin-acetaminophen-caffeine) can be effective for mild attacks 2, 1
• Treatment should begin as early as possible during an attack for maximum efficacy 1, 3

Second-Line Treatments

• Triptans should be offered to patients for whom over-the-counter analgesics provide inadequate headache relief 1, 3
• Triptans are most effective when taken early in an attack while headache is still mild 1, 4
• If one triptan is ineffective, others might still provide relief 1
• Sumatriptan has demonstrated significant efficacy in reducing headache severity from moderate/severe to mild/no pain within 2-4 hours compared to placebo 4
• Combining a triptan with an NSAID or acetaminophen improves efficacy 1, 3

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 2, 1, 3
• For patients with severe nausea or vomiting, consider non-oral routes of administration or adding an antiemetic such as metoclopramide or prochlorperazine 1, 3

Preventive Treatment

When to Consider Prevention

• 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; or presence of uncommon migraine conditions 1, 5

Preventive Medication Options

• Medications to prevent episodic migraine include angiotensin-receptor blockers, lisinopril, magnesium, topiramate, valproate, memantine, CGRP monoclonal antibodies, and atogepant 2
• AbobotulinumtoxinA can be used for prevention of chronic migraine but not episodic migraine 2
• Gabapentin is not recommended for prevention of episodic migraine 2
• Beta blockers, amitriptyline, and divalproex sodium have documented high efficacy with mild to moderate adverse events 5
• Amitriptyline can be used for prevention of chronic tension-type headache 2

Important Cautions and Considerations

• Avoid opioids and butalbital-containing analgesics for migraine treatment 1, 3
• Limit acute medication use to prevent medication overuse headache (≤15 days/month for NSAIDs, ≤10 days/month for triptans) 1, 3
• Be aware of potential side effects with triptans, including sensations of tightness, pain, pressure in the chest, throat, neck, and jaw 4
• Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's variant angina, Wolff-Parkinson-White syndrome, history of stroke or TIA, and uncontrolled hypertension 4
• Serotonin syndrome may occur with triptans, particularly during co-administration with SSRIs, SNRIs, TCAs, and MAO inhibitors 4

Lifestyle Modifications

• Address predisposing factors such as poor sleep quality, poor physical fitness, or stress 1
• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 1, 3
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1
• Physical therapy or aerobic exercise can be used in management of tension-type headaches and migraines 2
• Manage stress with relaxation techniques or mindfulness practices 1

Treatment Algorithm

1. For mild to moderate attacks: Start with NSAIDs (ibuprofen 400mg, aspirin 1000mg, naproxen sodium, or diclofenac potassium) or combination analgesics with caffeine 2, 1
2. For moderate to severe attacks or if NSAIDs fail: Use triptans (sumatriptan, rizatriptan, etc.) or combination of triptan with NSAID 1, 4
3. For patients with nausea/vomiting: Add antiemetics (metoclopramide, prochlorperazine) or use non-oral routes of administration 1, 3
4. For patients who fail triptans or have contraindications: Consider gepants, dihydroergotamine, or lasmiditan 1, 3
5. For frequent or disabling attacks: Consider preventive therapy with options based on comorbidities and contraindications 2, 1, 5