What are the treatment options for migraines?

Migraine Treatment Options

For acute 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 Strategy

First-Line Treatment (Mild to Moderate Attacks)

• NSAIDs with proven efficacy include acetylsalicylic acid (aspirin), ibuprofen, naproxen sodium, and diclofenac potassium 1, 2
• Combination analgesics containing acetaminophen plus aspirin plus caffeine are effective, but acetaminophen alone has less efficacy 1, 2
• Treatment should begin as early as possible during an attack for maximum efficacy 1, 2
• Appropriate dosing is essential - ensure patients are using adequate doses before considering them ineffective 3

Second-Line Treatment (Moderate to Severe Attacks)

• Triptans (sumatriptan, rizatriptan, naratriptan, zolmitriptan, etc.) should be offered to patients for whom over-the-counter analgesics provide inadequate relief 1, 2
• Triptans are most effective when taken early while headache is still mild 1, 4
• If one triptan is ineffective, others might still provide relief 1
• Clinical trials show that sumatriptan provides significant headache relief at 2 and 4 hours compared to placebo, with 50-62% of patients achieving relief at 2 hours 4

Combination Approaches

• Combining a triptan with an NSAID or acetaminophen improves efficacy 1, 2
• For patients with severe nausea or vomiting, consider non-oral routes of administration and adding antiemetics like metoclopramide or prochlorperazine 1, 2

Advanced Treatment Options for Refractory Migraines

• For patients who fail all available triptans or have contraindications, consider CGRP antagonists (gepants), dihydroergotamine (DHE), or lasmiditan (ditan) 1, 2
• Subcutaneous sumatriptan injection can be useful for patients with severe nausea/vomiting 1

Important Treatment Cautions

• Avoid opioids and butalbital-containing analgesics for migraine treatment 1, 2
• Limit acute medication use to prevent medication overuse headache (≤15 days/month for NSAIDs, ≤10 days/month for triptans) 1, 2
• Sumatriptan is 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 combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors 4

Preventive Treatment

• 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
• Effective preventive options include:
  • Beta blockers 2, 3
  • Topiramate (requires discussion of teratogenic effects with patients of childbearing potential) 1, 3
  • Candesartan 3
  • ACE inhibitors, ARBs, or SSRIs for patients who don't tolerate first-line options 1
• Start preventive medications at a low dose and gradually increase until desired outcomes are achieved 1
• Monitor treatment efficacy using a headache diary 1

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, 2, 3
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1
• Manage stress with relaxation techniques or mindfulness practices 1