What are the treatment options for migraines?

Migraine Treatment

Acute Treatment Algorithm

For acute migraine treatment, use a stepped care approach: start with NSAIDs for mild-to-moderate attacks, escalate to triptans for moderate-to-severe attacks or when NSAIDs fail, and reserve advanced therapies for refractory cases. 1, 2

First-Line: NSAIDs and Acetaminophen

• Begin treatment immediately at migraine onset with over-the-counter NSAIDs—the four with strongest evidence are aspirin, ibuprofen, naproxen sodium, and diclofenac potassium. 1, 2, 3
• Combination therapy of acetaminophen plus aspirin plus caffeine is effective for mild attacks, but acetaminophen alone has limited efficacy and should only be used if NSAIDs are not tolerated. 1, 2
• Take medication as early as possible during the attack for maximum effectiveness. 2, 3

Second-Line: Triptans

• Offer triptans to patients who fail NSAIDs or who have moderate-to-severe attacks from the outset. 1, 2, 3
• All seven triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, naratriptan) are effective, with sumatriptan demonstrating 52-62% headache response at 2 hours and 65-79% at 4 hours across doses of 25-100 mg. 4
• Administer triptans early while headache is still mild for optimal efficacy. 1, 3
• If one triptan fails, trial a different triptan as others may still provide relief. 1, 2
• Combining a triptan with an NSAID or acetaminophen improves efficacy beyond either agent alone—this combination therapy should be the standard approach. 1, 2, 3
• For patients with severe nausea/vomiting preventing oral intake, use subcutaneous sumatriptan injection or non-oral triptan formulations. 1, 2

Third-Line: Advanced Therapies

• For patients who fail all triptans or have contraindications (coronary artery disease, uncontrolled hypertension, Wolff-Parkinson-White syndrome, history of stroke), use CGRP antagonists (gepants: rimegepant, ubrogepant, zavegepant), lasmiditan (ditan), or dihydroergotamine. 1, 2, 4

Adjunctive Therapy for Nausea

• Add antiemetics (metoclopramide or prochlorperazine) for patients with significant nausea to treat the symptom and improve gastric motility for better medication absorption. 1, 2
• Consider non-oral routes of administration when nausea/vomiting is prominent. 1, 2

Critical Avoidances

• Do not use opioids or butalbital-containing analgesics for routine migraine treatment due to dependency risk and medication overuse headache. 1, 2
• Limit acute medication use to prevent medication overuse headache: ≤15 days/month for NSAIDs and ≤10 days/month for triptans. 1, 2, 4

Preventive Treatment Indications

Consider preventive therapy when patients have:

• Two or more attacks per month producing disability lasting ≥3 days per month 1, 3
• Contraindication to or failure of acute treatments 1, 3
• Use of acute medication more than twice per week 1, 3
• Uncommon migraine conditions (hemiplegic migraine, prolonged aura) 1

Preventive Medication Options

• First-line preventive options include beta-blockers (propranolol, timolol), topiramate, or candesartan. 1, 3
• Topiramate requires mandatory discussion of teratogenic effects with all patients of childbearing potential. 1, 3
• If first-line agents fail or are not tolerated, consider ACE inhibitors, ARBs, or SSRIs. 1
• Start preventive medications at low doses and gradually titrate until desired outcomes are achieved. 1

Monitoring Preventive Therapy

• Have patients maintain a headache diary tracking severity, frequency, duration, disability, treatment response, and adverse effects to determine efficacy and identify analgesic overuse. 1, 3
• Switch preventive treatment if adequate response is not achieved during a reasonable trial period. 1

Lifestyle Modifications

• Maintain regular meals and adequate hydration. 1, 2, 3
• Ensure sufficient and consistent sleep schedule. 1, 2, 3
• Engage in regular moderate-to-intense aerobic exercise. 1, 2, 3
• Implement stress management with relaxation techniques or mindfulness practices. 1, 2, 3
• Address poor sleep quality, poor physical fitness, and chronic stress as predisposing factors. 1

Key Clinical Pitfalls

• Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, history of stroke/TIA, or Wolff-Parkinson-White syndrome—perform cardiac evaluation if chest/throat/neck/jaw pain occurs after triptan use in high-risk patients. 4
• Monitor for serotonin syndrome when combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors—symptoms include mental status changes, autonomic instability, and neuromuscular aberrations. 4
• Medication overuse headache presents as daily migraine-like headaches or marked increase in attack frequency—detoxification with drug withdrawal may be necessary. 4