From the Guidelines
For daily migraines, I strongly recommend using erenumab, fremanezumab, or galcanezumab as preventive medications, as they have been shown to be effective in preventing episodic or chronic migraine 1. These medications are part of a class of drugs known as CGRP antagonists, which work by blocking the action of calcitonin gene-related peptide (CGRP), a protein that plays a key role in the development of migraine headaches. The use of these medications is supported by the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache, which recommends them as first-line treatment for the prevention of episodic or chronic migraine 1. In addition to preventive medications, acute treatments such as eletriptan, frovatriptan, rizatriptan, sumatriptan, or zolmitriptan can be used to treat migraine attacks 1. It is also important to implement lifestyle changes, such as regular sleep, staying hydrated, avoiding triggers, and practicing stress management, to help reduce the frequency and severity of migraine attacks. Other preventive medications, such as candesartan or telmisartan, may also be considered, although the evidence for their use is not as strong as it is for the CGRP antagonists 1. Overall, a comprehensive treatment approach that combines preventive medications, lifestyle modifications, and acute treatments can help to effectively manage daily migraines and improve quality of life. Key points to consider when treating daily migraines include:
- Using CGRP antagonists as first-line preventive medications
- Implementing lifestyle changes to reduce migraine frequency and severity
- Using acute treatments such as triptans or NSAIDs to treat migraine attacks
- Keeping a headache diary to identify patterns and triggers
- Considering other preventive medications, such as candesartan or telmisartan, if CGRP antagonists are not effective.
From the FDA Drug Label
The recommended dose of sumatriptan tablets is 25 mg, 50 mg, or 100 mg. Doses of 50 mg and 100 mg may provide a greater effect than the 25 mg dose, but doses of 100 mg may not provide a greater effect than the 50 mg dose. If the migraine has not resolved by 2 hours after taking sumatriptan tablets, or returns after a transient improvement, a second dose may be administered at least 2 hours after the first dose. The maximum daily dose is 200 mg in a 24-hour period
The treatment options for daily migraines (episodic or chronic headaches) using sumatriptan tablets include:
- Initial dose: 25 mg, 50 mg, or 100 mg
- Second dose: may be administered at least 2 hours after the first dose if the migraine has not resolved or returns after a transient improvement
- Maximum daily dose: 200 mg in a 24-hour period
- Frequency of treatment: the safety of treating an average of more than 4 headaches in a 30-day period has not been established 2 2
From the Research
Treatment Options for Daily Migraines
The treatment options for daily migraines, including both episodic and chronic headaches, can be categorized into several approaches.
- Pharmacologic Treatment: This can be either acute (abortive, symptomatic) or preventive (prophylactic) 3. Preventive medications are usually given daily for months or years and can be divided into two major categories: alternatives of high efficacy and second-line choices of high efficacy 3.
- Preventive Medications: The medications with the best-documented efficacy for preventive treatment include:
- Other Treatment Options:
- Lifestyle modifications and migraine trigger avoidance are recommended as preventive measures for all individuals with migraine 6.
- Nutraceuticals, such as coenzyme Q10, magnesium citrate, and riboflavin, have shown promise in preventive therapy 6.
- Neurostimulation and behavioral therapy, including biofeedback, cognitive-behavioral therapy, and relaxation therapy, can also be effective 6.
- Erenumab, a calcitonin gene-related peptide (CGRP) receptor monoclonal antibody, has been approved for the prevention of migraine 6.
- Considerations for Treatment Choice:
- The choice of preventive treatment depends on the individual drug's efficacy and side effects, the patient's wants, needs, and response to prior treatment, and the presence of any comorbid or coexistent disease 3.
- Comorbid medical and psychologic illnesses should be considered when choosing preventive drugs, as drug therapy may be beneficial for both disorders but also a potential confounder of optimal treatment 5.
- Patient preferences, headache profile, and the presence or absence of coexisting disorders should also be taken into account when selecting a preventive treatment 4, 5.