What is the treatment algorithm for migraines?

Migraine Treatment Algorithm

For acute migraine treatment, use a stratified-care approach where treatment intensity matches attack severity: NSAIDs or combination analgesics (aspirin + acetaminophen + caffeine) for mild-to-moderate attacks, and triptans for moderate-to-severe attacks, with early administration being critical for optimal efficacy. 1

Treatment Algorithm by Attack Severity

Mild-to-Moderate Migraine Attacks

First-Line Options:

• NSAIDs are the initial treatment of choice, including aspirin, ibuprofen, naproxen sodium, or diclofenac potassium 1
• Combination therapy with aspirin + acetaminophen + caffeine provides synergistic analgesia and enhanced absorption when NSAIDs alone are insufficient 1
• Begin treatment as early as possible during the attack to maximize efficacy 1

Adjunctive Therapy:

• Add antiemetics (metoclopramide 10 mg or prochlorperazine 10 mg) when nausea is present, as these provide both antiemetic effects and synergistic analgesia 1

Moderate-to-Severe Migraine Attacks

First-Line Triptan Therapy:

• Oral triptans are first-line for moderate-to-severe attacks: sumatriptan 50-100 mg, rizatriptan 10 mg, naratriptan 2.5 mg, or zolmitriptan 2.5-5 mg 1
• Sumatriptan 50 mg is the optimal starting dose, balancing efficacy (headache relief NNT 3.2) with tolerability comparable to placebo 2, 3
• Sumatriptan 100 mg provides marginally better efficacy (NNT 3.5) but higher adverse event rates (NNH 7.1) 2, 3
• Allow a second dose at least 2 hours after the first if headache persists or recurs, with maximum daily dose of 200 mg 4

Route Selection for Severe Attacks:

• Subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours; therapeutic gain 51%) for rapidly escalating or severe attacks 1, 5
• Intranasal sumatriptan 5-20 mg when significant nausea or vomiting prevents oral administration 1

Combination Approach:

• Combine triptans with fast-acting NSAIDs to prevent headache recurrence, which occurs in 30-40% of patients within 24 hours 1, 5

Parenteral Treatment for Severe Attacks (Emergency/Urgent Care Setting)

Recommended IV Combination:

• Metoclopramide 10 mg IV + ketorolac 30 mg IV is the first-line parenteral combination, providing rapid pain relief while minimizing rebound headache risk 1
• Prochlorperazine 10 mg IV is equally effective as metoclopramide and may be substituted 1
• Ketorolac has 6-hour duration with minimal rebound risk; use caution in renal impairment, GI bleeding history, or cardiovascular disease 1

Avoid in Routine Acute Treatment:

• Opioids should be reserved only for cases where other medications cannot be used, when sedation is acceptable, and abuse risk has been addressed 1
• Opioids lead to dependency, rebound headaches, and loss of efficacy with chronic use 1

Status Migrainosus (Severe Continuous Migraine >72 Hours)

Treatment Protocol:

1. IV corticosteroids are the mainstay treatment for status migrainosus 6
2. IV fluids for hydration + antiemetic therapy (metoclopramide or prochlorperazine) 6
3. If inadequate response within 1-2 hours, add parenteral ketorolac 6
4. For refractory cases, consider IV magnesium sulfate 6
5. Reserve opioids (meperidine, butorphanol nasal spray) only for cases not responding to above measures 6

Critical Medication-Overuse Headache Prevention

Frequency Limits:

• Limit acute therapy to no more than 2 days per week to prevent medication-overuse headache 1
• NSAIDs: ≥15 days/month causes medication-overuse headache 7
• Triptans: ≥10 days/month causes medication-overuse headache 7

When to Initiate Preventive Therapy:

• Headaches occur ≥2 days per month despite optimized acute therapy 1
• Acute medication use exceeds twice weekly 1
• Quality of life remains significantly impaired 1

Treatment Failure Algorithm

If Current Triptan Stops Working:

1. Rule out medication-overuse headache first if using acute medications >2 days/week 1
2. Try a different triptan, as failure of one does not predict failure of others 1
3. Ensure early administration during mild pain phase, not after pain becomes severe 1
4. Consider route change (e.g., subcutaneous if oral fails) particularly for rapid-onset attacks or vomiting 1
5. Add fast-acting NSAID to prevent the 40% recurrence rate within 48 hours 1
6. Transition to preventive therapy rather than increasing acute medication frequency 1

Stratified-Care vs. Step-Care Approach

The stratified-care approach is superior to step-care and should be used: assign treatment intensity based on attack severity and disability level from the outset, rather than starting all patients on the least expensive option and escalating only after failure 8. This approach improves outcomes by matching treatment to attack severity immediately 8.

Special Populations

Cardiovascular Disease:

• Avoid triptans; use NSAIDs or antiemetics as primary therapy 6

Pregnancy:

• Acetaminophen and antiemetics are preferred; avoid NSAIDs and triptans 6

Hepatic Impairment:

• Maximum single sumatriptan dose should not exceed 50 mg 4

Nonpharmacologic Adjuncts

• Relaxation training, thermal biofeedback combined with relaxation, electromyographic biofeedback, and cognitive-behavioral therapy may be effective for migraine prevention 8
• These behavioral therapies can be combined with preventive drug therapy for additional benefit 8