What is the drug of choice for treating migraines?

Drug of Choice for Migraine Treatment

Triptans are the drug of choice for treating moderate to severe migraine attacks, with NSAIDs recommended as first-line therapy for mild to moderate migraines. 1

First-Line Treatment Options

For Mild to Moderate Migraines:

• NSAIDs are recommended as first-line treatment due to their demonstrated efficacy and favorable tolerability profile 1
• Specific effective NSAIDs include aspirin, ibuprofen, naproxen sodium, and combination medications containing acetaminophen, aspirin, and caffeine 1

For Moderate to Severe Migraines:

• Triptans (serotonin 5-HT1B/1D agonists) are the recommended first-line therapy 2, 1
• Oral triptans with good evidence include:
  • Sumatriptan (25-100 mg)
  • Rizatriptan (5-10 mg)
  • Zolmitriptan (2.5-5 mg)
  • Naratriptan (1-2.5 mg) 2, 1

Route of Administration Considerations

• Subcutaneous sumatriptan (6 mg) provides the most rapid pain relief (within approximately 15 minutes) with efficacy rates of 70-82% 2, 3
• Non-oral routes should be selected when nausea or vomiting are significant components of the migraine attack 2, 1
• Available non-oral options include:
  • Subcutaneous sumatriptan (fastest onset of action) 2, 3
  • Intranasal sumatriptan or zolmitriptan 2, 4
  • Orally disintegrating tablets (rizatriptan, zolmitriptan) 4

Clinical Decision-Making Algorithm

1. Assess migraine severity:

   • Mild to moderate → Start with NSAIDs
   • Moderate to severe → Start with triptans 1

2. Consider presence of nausea/vomiting:

   • If significant → Choose non-oral route (subcutaneous, intranasal, orally disintegrating) 2, 1
   • If minimal → Oral route acceptable 1

3. Consider need for rapid onset:

   • If rapid relief critical → Subcutaneous sumatriptan (onset ~15 minutes) 2, 3
   • If standard relief acceptable → Oral triptans (onset 30-120 minutes) 2

4. If one triptan is ineffective:

   • Try a different triptan before abandoning this class of medication 2

Important Considerations and Cautions

• Triptans are contraindicated in patients with:

  • Ischemic heart disease or history of myocardial infarction
  • Uncontrolled hypertension
  • Basilar or hemiplegic migraine
  • Wolff-Parkinson-White syndrome or other cardiac conduction disorders 2, 5, 6, 5

• Medication overuse headache can result from frequent use of acute medications (more than 10 days per month), leading to increased headache frequency 5, 6, 5

• Serotonin syndrome may occur with triptans, particularly when co-administered with SSRIs, SNRIs, TCAs, or MAO inhibitors 5, 6, 5

• Patients should try a medication for 2-3 headache episodes before abandoning that treatment option 2

• Preventive therapy should be considered for patients with frequent migraines (≥2 attacks/month) or when acute treatments are contraindicated or ineffective 2