What are the treatment options for migraine management?

Migraine Management

Acute Treatment Algorithm

For acute migraine treatment, start with NSAIDs for mild-to-moderate attacks, escalate to triptans for moderate-to-severe attacks or NSAID failures, and use combination therapy (triptan + NSAID) for optimal efficacy. 1

First-Line Treatment: NSAIDs

• NSAIDs are the recommended first-line therapy for most migraine patients, with the strongest evidence supporting aspirin, ibuprofen, naproxen sodium, and diclofenac potassium. 2, 1

• Acetaminophen alone is ineffective and should not be used as monotherapy. 2

• The combination of acetaminophen-aspirin-caffeine is effective for mild attacks, but acetaminophen alone lacks efficacy. 2, 1

• Ensure patients use adequate NSAID dosages before declaring treatment failure. 3

Second-Line Treatment: Triptans

• Triptans should be used when NSAIDs provide inadequate relief or for moderate-to-severe attacks from the outset. 2, 1

• All seven triptans have good evidence for efficacy: sumatriptan (oral and subcutaneous), rizatriptan, eletriptan, zolmitriptan, naratriptan, almotriptan, and frovatriptan. 2, 1

• Administer triptans early in the attack while headache is still mild for maximum effectiveness. 1, 3

• If one triptan fails, trial another—individual response varies significantly between triptans. 1

• Combining a triptan with an NSAID improves efficacy beyond either agent alone. 1, 4

• Subcutaneous sumatriptan is particularly useful for patients with severe nausea/vomiting who cannot tolerate oral medications. 1

Contraindications to Triptans

Triptans are contraindicated in patients with: 2, 5

• Uncontrolled hypertension
• Coronary artery disease or Prinzmetal's angina
• History of stroke or transient ischemic attack
• Basilar or hemiplegic migraine
• Wolff-Parkinson-White syndrome or other cardiac accessory pathway disorders

Third-Line Treatment: Advanced Options

• For patients who fail all triptans or have contraindications, consider CGRP antagonists (gepants: rimegepant, ubrogepant, zavegepant), lasmiditan (ditan), or dihydroergotamine. 1

Managing Associated Symptoms

• Add antiemetics like metoclopramide or prochlorperazine for nausea/vomiting, which also improve gastric motility and medication absorption. 1, 4

• Use non-oral routes (nasal spray, subcutaneous injection) when nausea/vomiting is prominent. 1

Critical Medications to Avoid

• Do not use opioids or butalbital-containing analgesics for migraine treatment—they increase risk of medication overuse headache and dependency. 1, 3, 4

Medication Overuse Headache Prevention

• Limit acute medication use to ≤10 days per month for triptans and ≤15 days per month for NSAIDs to prevent medication overuse headache. 1, 4

• Consider preventive therapy if acute medications are needed more than twice weekly. 2

Preventive Treatment Indications

Consider preventive medications when patients have: 1

• 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
• Uncommon migraine conditions (hemiplegic migraine, prolonged aura)

Preventive Medication Options

• First-line preventive options include beta-blockers (propranolol, timolol), topiramate, or candesartan. 1, 4

• Topiramate requires discussion of teratogenic effects with patients of childbearing potential. 1

• Alternative options include ACE inhibitors, ARBs, or SSRIs if first-line agents are not tolerated. 1

• Start preventive medications at low doses and titrate gradually to desired effect. 1

Stratified vs. Step-Care Approach

• The stratified-care approach (matching treatment intensity to attack severity from the outset) is superior to step-care (starting with simple analgesics and escalating only after failure). 2

• Use NSAIDs for patients with mild disability and infrequent attacks. 2

• Use triptans immediately for patients with moderate-to-severe disability. 2

Non-Pharmacologic Interventions

• Counsel patients on lifestyle modifications: maintain regular meals, adequate hydration, consistent sleep schedule (7-9 hours), regular aerobic exercise, and stress management techniques. 1, 3, 4

• Relaxation training, thermal biofeedback combined with relaxation, electromyographic biofeedback, and cognitive-behavioral therapy have evidence for migraine prevention. 2

• Behavioral therapy can be combined with preventive medications for additive benefit. 2

Monitoring and Follow-Up

• Have patients maintain a headache diary tracking severity, frequency, duration, disability, treatment response, and adverse effects. 2, 1

• Encourage identification of migraine triggers (alcohol, caffeine, tyramine-containing foods, nitrates, stress, fatigue, perfumes, bright/flickering lights). 2

• Switch preventive treatment if adequate response is not achieved during a reasonable trial period. 1

Special Populations

Pregnancy

• Acetaminophen is the safest option during pregnancy. 6
• Sumatriptan may be considered for selected patients and is compatible with breastfeeding. 6

Elderly

• Blood pressure increases more significantly with triptans in elderly patients—monitor closely. 5
• Pharmacokinetics are similar to younger adults, though half-life is slightly prolonged (4.4 to 5.7 hours). 5

Pediatric

• Safety and effectiveness of triptans in pediatric patients are not established. 5