What are the treatment options for migraine headaches?

Treatment for Migraine Headache

Start with NSAIDs (ibuprofen 400-800 mg, naproxen 275-550 mg, or aspirin 650-1000 mg) or acetaminophen for mild to moderate migraine attacks, and escalate to triptans combined with NSAIDs for moderate to severe attacks or when first-line therapy fails. 1

First-Line Treatment Algorithm

For Mild to Moderate Migraine

• Begin with oral NSAIDs as monotherapy: ibuprofen 400-800 mg, naproxen sodium 275-550 mg, aspirin 650-1000 mg, or acetaminophen at appropriate dosages 1, 2
• Consider combination therapy with an NSAID plus acetaminophen for enhanced efficacy if monotherapy is insufficient 1
• Combination analgesics containing caffeine (aspirin plus acetaminophen plus caffeine) are also effective options 2
• Ensure you use adequate dosing before concluding treatment failure—increase the dose without exceeding maximum daily recommendations 1

For Moderate to Severe Migraine

• Initiate combination therapy with a triptan plus an NSAID or acetaminophen as early as possible after headache onset for superior efficacy compared to monotherapy 2, 3
• All triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, naratriptan, frovatriptan) are effective, with oral sumatriptan achieving headache response in 52-62% of patients at 2 hours and 65-79% at 4 hours 4, 5
• If one triptan is ineffective, trial another within the same class as individual response varies 2
• Subcutaneous sumatriptan injection should be used for patients who rapidly reach peak headache intensity or cannot tolerate oral medications due to vomiting 2

Second-Line Treatment Options

When first-line therapies fail or are contraindicated:

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant for patients who don't respond to or cannot tolerate triptans plus NSAIDs 1, 2
• Dihydroergotamine (DHE) as an alternative when first-line treatments fail 1, 2
• Antiemetics (metoclopramide or prochlorperazine) particularly when migraine is accompanied by nausea/vomiting 2

Third-Line Treatment Options

• Lasmiditan (ditan) for patients who don't respond to all other pharmacologic treatments 1, 2
• Intranasal lidocaine may be considered, though evidence for efficacy is limited 2

Critical Medication Overuse Thresholds

Monitor acute medication frequency carefully to prevent medication overuse headache:

• Limit NSAID use to <15 days per month 1, 3
• Limit triptan use to <10 days per month 1, 3
• When these thresholds are exceeded, medication overuse headache develops, worsening the underlying migraine pattern 1, 5

Absolute Contraindications and Cautions

Never Use:

• Opioids (meperidine, butorphanol) or butalbital-containing medications for acute migraine due to risks of dependency, rebound headaches, and loss of efficacy 1, 2, 5

Triptan Contraindications:

• Avoid triptans in patients with cardiovascular disease (coronary artery disease, peripheral vascular disease, cerebrovascular disease) or uncontrolled hypertension due to vasoconstrictive properties 1
• Triptans cause significant elevation in blood pressure in some patients, including hypertensive crisis 4

Special Population Considerations

Pregnancy:

• Acetaminophen is the safest first-line option during pregnancy 1
• NSAIDs may be used prior to third trimester 6
• Discuss medication risks during pregnancy and lactation before prescribing to patients of childbearing potential 2, 3

Severe Nausea/Vomiting:

• Use non-oral routes of administration (subcutaneous, intranasal, rectal) 2
• Add an antiemetic to the treatment regimen 2

When to Consider Preventive Therapy

• Initiate preventive medications when migraines occur ≥2 days per month or when acute treatment provides inadequate response despite optimization 3
• Topiramate is recommended as a first-choice preventive option due to lower cost 3

Essential Lifestyle Modifications

All patients should receive counseling on:

• Maintaining adequate hydration 1, 3
• Regular meal schedule 1, 3
• Sufficient and consistent sleep patterns 1, 3
• Regular moderate to intense aerobic exercise 1, 3
• Stress management through relaxation techniques or mindfulness 1, 3
• Identifying and avoiding individual migraine triggers 1
• Weight loss if overweight or obese, as obesity increases risk of chronic migraine transformation 3