What are the non-pharmacological, homeopathic, and pharmacological treatments for migraines?

Treatment of Migraines: Pharmacological and Non-Pharmacological Approaches

Acute Pharmacological Treatment

For moderate to severe episodic migraine, start with combination therapy of a triptan plus an NSAID (or acetaminophen if NSAIDs are contraindicated), as this provides superior efficacy compared to monotherapy. 1

First-Line Acute Treatment Algorithm

• Mild migraine: Begin with an NSAID (aspirin, ibuprofen, naproxen, diclofenac, or celecoxib) or acetaminophen, with an antiemetic if nausea is present 1

• Moderate to severe migraine: Use combination therapy with a triptan (sumatriptan, rizatriptan, eletriptan, almotriptan, naratriptan, frovatriptan, or zolmitriptan) plus an NSAID or acetaminophen 1

• Severe nausea/vomiting: Switch to nonoral triptan formulations (subcutaneous sumatriptan or intranasal formulations) combined with an antiemetic (metoclopramide or prochlorperazine) 1, 2

• Timing is critical: Counsel patients to begin treatment as soon as possible after migraine onset, ideally while pain is still mild, as this significantly improves efficacy 1, 2

Second-Line and Alternative Acute Treatments

If triptans fail or are contraindicated, consider these options in sequence 1:

• CGRP antagonists (gepants): Rimegepant, ubrogepant, or zavegepant for patients who do not tolerate or have inadequate response to triptan-NSAID combination 1

• Ergot alkaloid: Dihydroergotamine (intranasal or injectable) has good evidence for efficacy in intractable migraine 1, 2

• Ditan: Lasmiditan should be reserved for patients who have failed all other pharmacologic treatments in this guideline 1

Critical Medications to Avoid

Do not use opioids or butalbital for acute migraine treatment. 1 These medications increase the risk of medication overuse headache, dependency, and have limited efficacy evidence 2. Opioids should only be considered if all other medications cannot be used, abuse risk has been addressed, and sedation is not a concern 2.

Preventing Medication Overuse Headache

• Limit acute treatment to no more than 2 days per week to prevent medication overuse headache 2
• Medication overuse headache is defined as headache occurring ≥15 days/month for ≥3 months with NSAIDs, or ≥10 days/month with triptans 1, 2
• If acute medications are used more than twice weekly, initiate preventive therapy 2

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Preventive Pharmacological Treatment

Consider preventive therapy for patients experiencing ≥2 migraine days per month with significant disability despite optimized acute treatment. 1, 3

First-Line Preventive Medications

Start with one of these evidence-based options 1, 3:

• Beta-blockers: Propranolol (80-240 mg/day), metoprolol, atenolol, bisoprolol, or timolol (20-30 mg/day) 1, 3
• Topiramate: 100 mg/day (typically 50 mg twice daily) 1, 3
• Candesartan: Particularly useful for patients with comorbid hypertension 1, 3

Second-Line Preventive Medications

If first-line agents fail or are not tolerated 1, 3:

• Amitriptyline: 30-150 mg/day, particularly effective in patients with mixed migraine and tension-type headache 1, 3
• Flunarizine: Effective where available 1, 3
• Sodium valproate/divalproex sodium: 800-1500 mg/day, but strictly contraindicated in women of childbearing potential due to teratogenic effects 1, 3

Third-Line Preventive Medications

CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) should be considered when first- and second-line treatments have failed or are contraindicated 1, 3. Efficacy should be assessed only after 3-6 months of treatment 3.

Implementation Strategy

• Start low, titrate slowly: Begin with a low dose and increase gradually until clinical benefits are achieved or side effects limit further increases 3
• Adequate trial period: Allow 2-3 months before determining efficacy for most medications 1, 3
• Duration of therapy: Consider pausing preventive treatment after 6-12 months of successful therapy to determine if it can be discontinued 1, 3
• Monitoring: Use headache diaries to track attack frequency, severity, duration, disability, and treatment response 3

Common Pitfalls to Avoid

• Starting with too high a dose, leading to poor tolerability and discontinuation 3
• Inadequate duration of preventive trial (less than 2-3 months) 3
• Failing to recognize medication overuse headache from frequent use of acute medications 3
• Using valproate in women of childbearing potential 3

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Non-Pharmacological Treatments

Non-pharmacological therapies should be offered to all patients as adjuncts to medication or as stand-alone treatments when medications are contraindicated. 1

Evidence-Based Behavioral Therapies

These have the strongest evidence and should be considered first-line non-pharmacological options 1, 4:

• Cognitive-behavioral therapy (CBT): Proven effective for migraine prevention 1
• Biofeedback: Thermal biofeedback combined with relaxation training has good evidence 1, 4
• Relaxation training: Including progressive muscle relaxation, visualization/guided imagery, and meditative therapy (abdominal breathing exercises) 1, 4
• Electromyographic biofeedback: Demonstrated efficacy in randomized trials 1, 4

Neuromodulation Devices

Non-invasive neuromodulation has strong evidence for effectiveness 1, 3, 5:

• Transcranial magnetic stimulation (TMS): Strong evidence for efficacy in chronic migraine 5
• Transcranial direct current stimulation (tDCS): Promising efficacy demonstrated 5
• Transcutaneous electrical nerve stimulation (TENS): Evidence supports use 5

Acupuncture

• Acupuncture can be considered as an adjunct or stand-alone treatment 1, 3, 4
• Important caveat: Studies indicate acupuncture is not superior to sham acupuncture in controlled trials, suggesting a significant placebo effect 1, 5
• Despite this, it may be useful as a first-line intervention for patients who prefer this approach 4

Lifestyle Modifications and Trigger Management

All patients should be counseled on these evidence-based lifestyle interventions 1, 6:

• Hydration: Stay well hydrated 1
• Regular meals: Maintain consistent eating patterns 1
• Sleep hygiene: Secure sufficient and consistent sleep 1, 6
• Exercise: Engage in regular moderate to intense aerobic exercise (40 minutes three times per week was as effective as topiramate in one randomized trial) 1
• Stress management: Use relaxation techniques or mindfulness practices 1, 6
• Weight management: Pursue weight loss for those who are overweight or obese 1
• Trigger identification: Use headache diaries to identify and avoid environmental, dietary, and behavioral triggers 1, 6, 4

Dietary Supplements

These have limited but potentially useful evidence 7, 4:

• Riboflavin (Vitamin B2): Shown efficacy in more than one randomized trial 7, 4
• Magnesium: Probably effective based on available evidence 7
• Coenzyme Q10: May be helpful 6
• Butterbur extract (Petasites): Probably effective but use with caution due to potential hepatotoxicity 7

Treatments with Limited or No Evidence

Do not recommend these as primary interventions 1:

• Physical therapy: Little to no evidence exists 1
• Spinal manipulation: Limited evidence 1
• Dietary approaches: Limited evidence 1
• Cervical manipulation, occlusal adjustment, hyperbaric oxygen: Mixed results 1

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Special Populations

Pregnancy and Lactation

• Discuss adverse effects of all pharmacologic treatments during pregnancy and lactation with patients of childbearing potential 1, 2
• Treatment decisions must weigh maternal disability against fetal/neonatal risks 2
• Non-pharmacological approaches become particularly important in this population 1

Comorbidities

• Identify and treat comorbid conditions including depression, sleep disturbances, obesity, and cardiovascular risk factors 2
• Select medications that address both migraine and comorbidities (e.g., amitriptyline for migraine and depression, topiramate for migraine and weight management) 2
• Candesartan is particularly useful for patients with comorbid hypertension 1, 3

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Homeopathic Treatments

There is no high-quality evidence supporting homeopathic treatments for migraine in the provided guidelines. The evidence-based guidelines focus exclusively on conventional pharmacological treatments, non-pharmacological behavioral therapies, neuromodulation, and specific dietary supplements with demonstrated efficacy in randomized controlled trials. Homeopathy is not mentioned in any of the major clinical practice guidelines reviewed 1, 3, 2.