What are the treatment options for migraine management?

Migraine Management

Acute Treatment Algorithm

For mild-to-moderate migraine attacks, start with NSAIDs (aspirin, ibuprofen, naproxen sodium, or diclofenac potassium) as first-line therapy; escalate to triptans for moderate-to-severe attacks or when NSAIDs fail, and administer triptans early while headache is still mild for maximum effectiveness. 1

First-Line Acute Treatment

• NSAIDs are the initial choice for most migraine patients with mild-to-moderate attacks, with strongest evidence supporting aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 2
• Acetaminophen has less efficacy than NSAIDs and should only be used in patients intolerant of NSAIDs 3
• Combination analgesics containing acetaminophen, aspirin, and caffeine can be effective for mild attacks, as caffeine provides synergistic analgesia 3, 2

Triptan Therapy

• Triptans should be used when NSAIDs provide inadequate relief or for moderate-to-severe attacks from the outset 1
• Administer triptans early in the attack while headache is still mild for maximum effectiveness—this timing is critical for optimal response 1, 3
• If one triptan fails, try a different triptan, as failure of one does not predict failure of others 3, 2
• Combining a triptan with an NSAID improves efficacy beyond either agent alone 1, 3
• Subcutaneous sumatriptan provides the highest efficacy (59% complete pain relief at 2 hours) but with higher adverse event rates 2
• Intranasal formulations (sumatriptan 5-20mg or other nasal spray triptans) are useful for patients with significant nausea or vomiting 2

Advanced Acute Treatment Options

• For patients who fail all available triptans or have contraindications, options include CGRP antagonists (gepants) like rimegepant, ubrogepant, or zavegepant; dihydroergotamine (DHE); or lasmiditan (ditan) 3
• Antiemetics like metoclopramide (10mg IV) or prochlorperazine (10mg IV) treat nausea and provide synergistic analgesia for migraine pain—not just for vomiting patients 3, 2
• For severe attacks requiring IV treatment: metoclopramide (10mg IV) plus ketorolac (30mg IV) is first-line combination therapy, providing rapid pain relief with minimal rebound headache risk 2

Critical Medication Overuse Prevention

• Avoid opioids and butalbital-containing analgesics for migraine treatment, as they lead to dependency, rebound headaches, and loss of efficacy 3, 2
• Limit acute medication use to prevent medication overuse headache: ≤15 days/month for NSAIDs, ≤10 days/month for triptans, and no more than twice weekly overall 3, 2

Preventive Treatment Indications

Consider preventive medications when patients have two or more attacks per month producing disability lasting ≥3 days per month, contraindication to or failure of acute treatments, or use of acute medication more than twice per week. 1, 3

First-Line Preventive Options

• Beta-blockers, topiramate, or candesartan are first-line preventive options 1
• Topiramate requires discussion of teratogenic effects with patients of childbearing potential 1, 3
• If first-line agents are not tolerated or result in inadequate response, consider an ACE inhibitor, ARB, or SSRI 3
• Start preventive medications at a low dose and gradually increase until desired outcomes are achieved 3
• Allow adequate trial periods: 2-3 months for oral agents, 3-6 months for CGRP monoclonal antibodies, and 6-9 months for onabotulinumtoxinA 2

Non-Pharmacologic Interventions

• Counsel patients on lifestyle modifications: maintain regular meals, adequate hydration, consistent sleep schedule, regular aerobic exercise (moderate to intense), and stress management techniques 1, 3
• Relaxation training, thermal biofeedback combined with relaxation, electromyographic biofeedback, and cognitive-behavioral therapy have evidence for migraine prevention 1

Monitoring Strategy

• Have patients maintain a headache diary tracking severity, frequency, duration, disability, treatment response, and adverse effects to determine treatment efficacy, identify analgesic overuse, and monitor migraine progression 1, 3
• Switch preventive treatment if an adequate response is not achieved during a reasonable trial period 3

Common Pitfalls to Avoid

• Do not allow patients to increase frequency of acute medication use in response to treatment failure—this creates a vicious cycle of medication overuse headache; instead transition to preventive therapy while optimizing acute treatment strategy 2
• Do not restrict antiemetics only to vomiting patients, as nausea itself is one of the most disabling symptoms and warrants treatment 2
• Ensure early triptan administration—delayed dosing significantly reduces efficacy 1, 3
• Do not assume all triptans are equivalent for a given patient—individual response varies, and switching triptans is appropriate if one fails 3, 2