What are the treatment options for migraine headache management?

Migraine Headache Management

Acute Treatment Algorithm

For most migraine sufferers, NSAIDs are first-line therapy, with aspirin, ibuprofen, naproxen sodium, or diclofenac potassium being the most effective options; if NSAIDs fail, escalate to triptans as second-line therapy. 1, 2

First-Line: NSAIDs

• Start treatment as early as possible during an attack for maximum efficacy—waiting reduces effectiveness 1, 2
• Ibuprofen 400 mg is more effective than 200 mg, with number needed to treat (NNT) of 3.2 for 2-hour headache relief versus placebo 3
• Aspirin, ibuprofen, naproxen sodium, and diclofenac potassium have the strongest evidence for efficacy 4, 1
• Combination therapy of acetaminophen plus aspirin plus caffeine is effective, but acetaminophen alone is not recommended 4, 1, 2
• Soluble formulations of ibuprofen provide more rapid 1-hour relief compared to standard tablets 3

Second-Line: Triptans

• Use triptans when NSAIDs have failed or for moderate-to-severe attacks 4, 2
• Oral sumatriptan, rizatriptan, naratriptan, and zolmitriptan all have good evidence for efficacy 4, 5
• Sumatriptan 50 mg and 100 mg are more effective than 25 mg, with 61-62% achieving headache response at 2 hours versus 27% with placebo 5
• Take triptans early while headache is still mild for best results 2
• If one triptan fails, try another—individual response varies 2
• For severe nausea or vomiting, use non-oral routes (subcutaneous sumatriptan or DHE nasal spray) 4, 2

Adjunctive Antiemetic Therapy

• Treat nausea with antiemetics even if the patient is not vomiting—nausea itself is disabling 4
• Metoclopramide or prochlorperazine are recommended options 2
• Consider non-oral routes of administration for patients who present early with significant nausea or vomiting 4, 2

Third-Line Options

• For patients who fail all triptans or have contraindications, consider CGRP antagonists (gepants), ditans, or dihydroergotamine 2
• Oral opiate combinations and butorphanol may be considered only when sedation is acceptable and abuse risk has been addressed 4

Medications to Avoid

Avoid opioids, butalbital-containing medications, and oral ergot alkaloids due to questionable efficacy, adverse effects, dependency risk, and potential for medication overuse headache 1, 2, 6

Preventive Therapy Indications

Evaluate all migraine sufferers for preventive therapy if they meet any of these criteria: 4, 2

• Two or more attacks per month producing disability lasting 3 or more days
• Contraindication to or failure of acute treatments
• Use of abortive medication more than twice per week
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction)

First-Line Preventive Agents

Recommended first-line preventive medications include: 4, 2

• Propranolol 80-240 mg/day
• Timolol 20-30 mg/day
• Amitriptyline 30-150 mg/day
• Divalproex sodium 500-1500 mg/day or sodium valproate 800-1500 mg/day

Preventive Therapy Principles

• Start with a low dose and titrate slowly until clinical benefits are achieved or limited by adverse events 4
• Allow 2-3 months for full therapeutic effect before declaring treatment failure 4
• Avoid overuse of acute medications (ergotamine, frequent NSAIDs or triptans) during preventive therapy 4
• After achieving stability, consider tapering or discontinuing preventive treatment 4

Medication Overuse Headache Risk

Be vigilant about medication overuse headache, defined as: 1, 2, 6

• ≥15 days per month with NSAIDs
• ≥10 days per month with triptans

Lifestyle Modifications

Counsel all patients on these evidence-based lifestyle interventions: 2, 6

• Maintain adequate hydration
• Eat regular meals
• Ensure sufficient and consistent sleep
• Engage in regular physical activity
• Practice stress management techniques
• Pursue weight loss if overweight or obese

Common Pitfalls to Avoid

• Do not use dexamethasone routinely for acute migraine—it is not supported by guidelines 1
• Do not delay treatment—early intervention is critical for efficacy 1, 2
• Do not restrict antiemetics only to vomiting patients—treat nausea aggressively as it is independently disabling 4
• Do not continue the same triptan if ineffective—try a different triptan before abandoning the class 2