What are the treatment options for migraine headache management?

Migraine Headache Management

Acute Treatment Algorithm

For mild to moderate migraine attacks, start with NSAIDs as first-line therapy; for moderate to severe attacks or NSAID failures, use triptans as first-line therapy. 1, 2

First-Line Treatment by Attack Severity

Mild to Moderate Attacks:

• NSAIDs are the recommended first-line therapy, with specific evidence-based options including ibuprofen (400-800 mg), naproxen sodium (500-550 mg), aspirin (900-1000 mg), or diclofenac potassium (50-100 mg) 1, 2
• Combination therapy with acetaminophen + aspirin + caffeine is effective and recommended when NSAIDs alone provide inadequate relief 1, 3
• Acetaminophen alone is NOT recommended as monotherapy for migraine 1
• Begin treatment as early as possible during the attack for maximum efficacy 1, 2

Moderate to Severe Attacks:

• Triptans are first-line therapy for moderate to severe migraine or when NSAIDs fail 1, 2
• Evidence-based triptan options include sumatriptan (50-100 mg), rizatriptan (5-10 mg), naratriptan (2.5 mg), zolmitriptan (2.5-5 mg), eletriptan (40-80 mg), almotriptan (12.5 mg), and frovatriptan (2.5 mg) 1, 2, 4
• Triptans are most effective when taken early while headache is still mild 1
• If one triptan fails, try a different triptan as response varies between agents 1
• Sumatriptan 50-100 mg provides headache response (reduction to mild or no pain) in 50-62% of patients at 2 hours versus 17-27% with placebo 4

Treatment for Attacks with Severe Nausea/Vomiting

When significant nausea or vomiting is present:

• Use non-oral triptan formulations: intranasal sumatriptan (5-20 mg) or subcutaneous sumatriptan (6 mg) 2, 4
• Subcutaneous sumatriptan 6 mg provides the highest efficacy with 59% achieving complete pain relief by 2 hours 2
• Add antiemetics: metoclopramide (10 mg IV/oral) or prochlorperazine (10 mg IV/oral) 1, 2

Combination Therapy Strategy

For enhanced efficacy, combine medications:

• Triptan + NSAID combination improves efficacy over either agent alone 1
• Acetaminophen + aspirin + caffeine combination is effective for moderate attacks 1, 3

Refractory Migraine (Third-Line Treatment)

For patients who fail all triptans or have contraindications:

• CGRP antagonists (gepants) 1
• Ditans 1
• Dihydroergotamine (DHE) - intranasal or IV formulations have good evidence for efficacy 1, 2

Intravenous Treatment for Severe Attacks

For severe migraine requiring IV therapy:

• Ketorolac 30 mg IV + metoclopramide 10 mg IV is the recommended first-line IV combination 2
• Alternative: prochlorperazine 10 mg IV (comparable efficacy to metoclopramide) 2
• Dihydroergotamine IV is an alternative option 2

Critical Medications to AVOID

Do NOT routinely use:

• Opioids (including hydromorphone, oxycodone) - lead to dependency, medication overuse headache, and loss of efficacy 1, 2, 5
• Butalbital-containing compounds - risk of dependency and medication overuse headache 1, 2
• Dexamethasone or corticosteroids - not supported by guidelines for routine acute migraine treatment 3
• Opioids should only be reserved for cases where all other medications cannot be used, sedation is not a concern, and abuse risk has been addressed 2

Medication Overuse Headache Prevention

Critical frequency limits to prevent medication overuse headache:

• NSAIDs: limit to <15 days per month 1
• Triptans: limit to <10 days per month 1
• Acute treatment should not exceed 2 times per week 2
• Frequent use leads to rebound headaches and increasing headache frequency 1, 2

Preventive Therapy Indications

Consider preventive medications when:

• Attacks occur frequently enough to warrant daily medication 1
• Options include propranolol, timolol, amitriptyline, or divalproex sodium/sodium valproate 1

Lifestyle Modifications

Counsel all patients on:

• Maintaining adequate hydration 1
• Regular meals 1
• Sufficient and consistent sleep 1
• Regular physical activity 1
• Stress management techniques 1
• Weight loss if overweight or obese 1

Common Pitfalls to Avoid

• Do not delay treatment - early administration during an attack significantly improves efficacy 1, 2
• Do not use acetaminophen alone - it is ineffective as monotherapy for migraine 1
• Do not establish patterns of frequent opioid use - this leads to medication overuse headache and dependency 2
• Do not assume all triptans are equivalent - if one fails, try another as individual response varies 1
• Do not use oral medications when severe nausea/vomiting is present - use non-oral routes (intranasal, subcutaneous, or IV) 2