What are the treatment options for migraine headaches?

Migraine Headache Treatment

First-Line Treatment Based on Attack Severity

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen sodium 550 mg, or aspirin 650-1000 mg); for moderate to severe attacks or those not responding to NSAIDs, add a triptan to the NSAID regimen. 1

Mild to Moderate Attacks

• NSAIDs are the recommended first-line treatment for mild to moderate migraine attacks due to their demonstrated efficacy and favorable tolerability profile 2
• Ibuprofen 400-800 mg every 6 hours is the most effective over-the-counter option, with NNT of 3.2 for 2-hour headache relief 3, 4
• Naproxen sodium 275-550 mg provides longer duration of action 3
• Aspirin 650-1000 mg every 4-6 hours has proven efficacy 3
• Avoid acetaminophen monotherapy—it is ineffective for migraine 3
• Combination therapy with aspirin plus acetaminophen plus caffeine is effective when NSAIDs alone provide inadequate relief 2

Moderate to Severe Attacks

• The American College of Physicians strongly recommends adding a triptan to an NSAID for moderate to severe attacks that do not respond adequately to NSAIDs alone (strong recommendation; moderate-certainty evidence) 1
• If acetaminophen was tried first, add a triptan to acetaminophen (conditional recommendation; low-certainty evidence) 1
• Triptans should be taken early when pain is still mild for maximum effectiveness 3

Specific Triptan Selection

• Oral triptans with strong evidence include sumatriptan, rizatriptan, naratriptan, and zolmitriptan 2
• Rizatriptan 10 mg has the fastest peak concentration 3
• Sumatriptan 50-100 mg provides 2-hour headache relief in 50-62% of patients versus 17-27% with placebo 5
• Subcutaneous sumatriptan 6 mg provides highest efficacy (59% complete pain relief at 2 hours) but with higher adverse event rates 2, 5
• Intranasal sumatriptan (5-20 mg) or nasal spray triptans are preferred when significant nausea or vomiting is present 2
• If one triptan fails, try a different triptan—patients should trial 2-3 headache episodes before switching 3

Intravenous Treatment for Severe Attacks

• For severe migraine requiring IV treatment, use metoclopramide 10 mg IV plus ketorolac 30 mg IV as first-line combination therapy 2
• Prochlorperazine 10 mg IV is equally effective to metoclopramide and relieves both headache pain and nausea 2
• Dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy 2
• Avoid opioids—they lead to dependency, rebound headaches, and eventual loss of efficacy 2

Antiemetic Adjuncts

• Metoclopramide 10 mg IV provides synergistic analgesia beyond treating nausea alone 2
• Prochlorperazine 10 mg IV is comparable to metoclopramide in efficacy 2
• Use antiemetics as adjuncts, not as primary monotherapy, and avoid frequent use to prevent medication-overuse headache 2

Critical Medication-Overuse Warning

• Limit acute treatment to no more than 2 days per week to prevent medication-overuse headache 1, 3
• Medication-overuse headache results from frequent use of acute medications (more than twice weekly), leading to increasing headache frequency and potentially daily headaches 2
• Rebound headache is associated with withdrawal of analgesics or abortive migraine medication 2

Preventive Therapy Indications

• If headaches occur more than 2-3 times per week, evaluate for preventive therapy rather than relying on acute treatment 2
• Propranolol 80-240 mg/day is first-line preventive medication with strong evidence 3
• Topiramate 100 mg/day is highly effective for prevention 3
• Start preventive medications low and titrate slowly over 2-3 months to assess efficacy 3

Treatment Algorithm Summary

1. Mild-moderate attacks: Start with NSAID monotherapy (ibuprofen 400-800 mg preferred) 2, 3
2. NSAID failure or moderate-severe attacks: Add triptan to NSAID (combination therapy) 1
3. Severe attacks with nausea/vomiting: Use intranasal or subcutaneous triptan formulations 2
4. Emergency department/urgent care: IV metoclopramide 10 mg plus ketorolac 30 mg 2
5. Frequent attacks (>2 days/week): Initiate preventive therapy 2, 3

Special Populations

• Pregnancy: Acetaminophen is the safest option; sumatriptan may be considered for selected patients 6
• Contraindications to vasoconstrictors: Use NSAIDs, combination analgesics, and dopamine antagonists 6
• Renal impairment or GI bleeding history: Use ketorolac with caution 2