Treatment Options for Migraines
For acute, episodic, moderate to severe migraine headaches, 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
First-Line Acute Treatment Options
- Begin with NSAIDs (aspirin, celecoxib, diclofenac, ibuprofen, or naproxen) or acetaminophen at appropriate dosages for mild to moderate migraine attacks 1
- Consider increasing the dosage of NSAIDs or acetaminophen (without exceeding maximum daily dose) if pain relief is insufficient 1
- For patients who don't achieve sufficient relief with NSAIDs or acetaminophen, add a triptan (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan) 1, 2
- Combination therapy (triptan plus NSAID or acetaminophen) is more effective than monotherapy and should be initiated as soon as possible after migraine onset 1, 2
- Triptans are most effective when taken early in an attack while headache is still mild 2
Advanced Treatment Options
- For patients who fail all available triptans or have contraindications to triptans, consider: 1, 2
- CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant
- Ergot alkaloids: dihydroergotamine (DHE)
- Ditans: lasmiditan
- For patients with severe nausea or vomiting, consider: 1, 2
- Non-oral routes of administration (e.g., subcutaneous sumatriptan injection)
- Adding antiemetics like metoclopramide or prochlorperazine
Important Cautions and Contraindications
- Avoid opioids and butalbital-containing medications for migraine treatment 1, 2
- Be aware of medication overuse headache risk: limit acute medication use to ≤15 days/month for NSAIDs and ≤10 days/month for triptans 1, 2
- Triptans are contraindicated in patients with: 3, 4
- Coronary artery disease or Prinzmetal's variant angina
- History of stroke or TIA
- Uncontrolled hypertension
- Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders
- Monitor for serotonin syndrome when combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors 3, 4
Preventive Treatment Considerations
- Consider preventive therapy for patients with: 2, 5
- Two or more attacks per month producing disability
- Attacks lasting 3+ days per month
- Contraindication to or failure of acute treatments
- Use of acute medication more than twice per week
- First-line preventive options include: 5
- Beta-blockers (propranolol, metoprolol)
- Anticonvulsants (topiramate, divalproex, valproate)
- CGRP receptor antagonists
- For chronic migraine, consider onabotulinumtoxinA injections 5
Non-Pharmacological Approaches
- Lifestyle modifications are important adjuncts to pharmacological treatment: 1, 2, 6
- Maintain regular meals and hydration
- Ensure sufficient and consistent sleep
- Engage in regular physical activity, preferably moderate to intense aerobic exercise
- Manage stress with relaxation techniques or mindfulness practices
- Consider weight loss for overweight or obese patients
- Identify and manage individual migraine triggers 6
- Consider complementary approaches such as acupuncture, biofeedback, and dietary supplements (riboflavin, coenzyme Q10, magnesium) for patients interested in non-pharmacological options 6, 5
Monitoring and Follow-up
- Use headache diaries to monitor treatment efficacy, identify analgesic overuse, and track migraine progression 2
- If preventive treatment doesn't provide adequate response after a reasonable trial period (typically 2-3 months), consider switching to another option 2
- Educate patients about medication overuse headache and the importance of limiting acute medication use 1, 2