Episodic Migraine Management
First-Line Treatment Approach
For moderate to severe episodic migraine, initiate combination therapy with a triptan plus an NSAID (or acetaminophen if NSAIDs are contraindicated), as this provides superior efficacy compared to either agent alone. 1, 2
Stepwise Treatment Algorithm
Step 1: Assess Current Treatment
- Verify if the patient has tried an NSAID or acetaminophen at adequate dosing for their migraine attacks 1
- If underdosed, increase to the maximum recommended daily dose before escalating therapy 1
- For mild episodic migraine specifically, an NSAID, acetaminophen, or their combination may suffice 1
Step 2: Initiate Combination Therapy for Moderate-Severe Attacks
- Add a triptan to an NSAID (or to acetaminophen when NSAIDs are contraindicated or not tolerated) 1, 2
- Begin treatment as soon as possible after headache onset to maximize efficacy 1, 2
- Available triptans include: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan 1
- Fast-acting triptans (rizatriptan 10 mg, eletriptan 40 mg, almotriptan 12.5 mg, zolmitriptan 2.5-5 mg, sumatriptan 100 mg) show similar high efficacy 3
Triptan Selection Considerations
- Sumatriptan 100 mg achieves pain-free status at 2 hours in approximately 30% of patients (NNT 4.7 vs placebo), with headache relief in approximately 60% (NNT 3.5) 4
- Patients who fail one triptan may respond to another within the same class 1
- Route of administration should be individualized: oral for standard cases, nonoral (intranasal, subcutaneous) for patients with severe nausea or vomiting 1
Second-Line Options for Refractory Cases
If combination therapy with a triptan plus NSAID/acetaminophen fails or is not tolerated, consider CGRP antagonists (gepants) as the next option. 1, 2, 5
Treatment Escalation Hierarchy
Second-Line:
- CGRP antagonists-gepants: rimegepant, ubrogepant, or zavegepant 1, 5
- Ergot alkaloid: dihydroergotamine (particularly intranasal formulation) 1, 5
Third-Line (Reserve for All Other Failures):
- Lasmiditan (ditan class) should only be used when patients have inadequate response to all other pharmacologic treatments in this guideline 1, 5
Critical Warnings and Contraindications
Medications to Avoid
Do not use opioids or butalbital-containing compounds for acute episodic migraine treatment. 1, 5
Medication Overuse Headache Prevention
- Limit acute medication use to prevent medication overuse headache, defined as headache occurring ≥15 days per month for ≥3 months due to medication overuse 1, 5
- Thresholds vary by drug class: ≥15 days/month for NSAIDs; ≥10 days/month for triptans 1, 5
- If episodic migraine occurs frequently or treatment provides inadequate response, add preventive medications 1, 5
Cardiovascular Precautions with Triptans
- Triptans can cause coronary artery vasospasm, myocardial ischemia, and arrhythmias 7
- Patients with multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD) require cardiovascular evaluation before receiving triptans 7
- Contraindicated in patients with ischemic or vasospastic coronary artery disease, uncontrolled hypertension, or history of stroke 7
Adjunctive Management
Antiemetic Use
- Add an antiemetic for patients with severe nausea or vomiting 1
- Consider nonoral triptan formulations when gastrointestinal symptoms are prominent 1
Lifestyle Modifications
- Stay well hydrated and maintain regular meals 1, 2
- Ensure sufficient and consistent sleep patterns 2
- Engage in regular moderate to intense aerobic exercise 2
- Manage stress with relaxation techniques or mindfulness practices 2
- Pursue weight loss if overweight or obese 2
- Identify and avoid personal migraine triggers 2