What are the treatment options for migraines?

Migraine Treatment

For acute migraine treatment, start with NSAIDs (ibuprofen, naproxen, aspirin, or diclofenac) for mild-to-moderate attacks, escalate to triptans for moderate-to-severe attacks or when NSAIDs fail, and reserve CGRP antagonists (gepants), lasmiditan, or dihydroergotamine for triptan-refractory cases. 1

Acute Treatment Algorithm

First-Line: Mild-to-Moderate Attacks

• Begin with NSAIDs immediately at migraine onset while pain is still mild for maximum efficacy 1, 2
• Proven effective NSAIDs include:
  • Ibuprofen 400-800 mg 1, 2
  • Naproxen sodium 500-825 mg 1, 2
  • Aspirin 900-1000 mg 1, 2
  • Diclofenac potassium 50-100 mg 1, 2
• Acetaminophen 1000 mg is less effective than NSAIDs and should only be used when NSAIDs are contraindicated 1
• Combination therapy with acetaminophen + aspirin + caffeine is effective for mild attacks 1, 2

Second-Line: Moderate-to-Severe Attacks or NSAID Failure

• Triptans are the cornerstone for moderate-to-severe migraine or when NSAIDs provide inadequate relief after 2-3 attacks 1, 3
• All seven triptans have proven efficacy: sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, naratriptan 1, 2
• Take triptans early in the attack while headache is still mild for optimal efficacy 1, 4
• Oral sumatriptan 50-100 mg achieves headache response in 50-62% at 2 hours and 68-79% at 4 hours 4
• If one triptan fails after adequate trial, try a different triptan as failure of one does not predict failure of others 1
• Combine triptan with NSAID for superior efficacy and reduced headache recurrence (40% recurrence rate within 48 hours with monotherapy) 1, 2

Route Selection Based on Symptoms

• For severe nausea/vomiting, use non-oral routes: subcutaneous sumatriptan 6 mg (59% pain-free at 2 hours), intranasal sumatriptan 5-20 mg, or intranasal zolmitriptan 1, 2
• Add antiemetics (metoclopramide 10 mg or prochlorperazine 10 mg) 20-30 minutes before oral medications for synergistic analgesia and improved gastric motility 1, 2

Third-Line: Triptan-Refractory or Contraindicated

• For patients who fail all triptans or have cardiovascular contraindications, escalate to 1, 2:
  • CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant
  • Lasmiditan (ditan)
  • Dihydroergotamine (DHE) intranasal or IV

Emergency/Rescue Treatment

• IV combination therapy: metoclopramide 10 mg + ketorolac 30 mg provides rapid relief with minimal rebound risk 2
• Prochlorperazine 10 mg IV is equally effective to metoclopramide 2
• Avoid opioids and butalbital-containing compounds due to dependency risk, medication overuse headache, and loss of efficacy 1, 2

Critical Medication Overuse Prevention

• Limit acute medication use to prevent medication overuse headache: ≤10 days/month for triptans, ≤15 days/month for NSAIDs 1, 2
• If using acute medications >2 days/week, initiate preventive therapy immediately 1

Preventive Therapy Indications

Start preventive treatment when 1:

• ≥2 attacks per month causing ≥3 days of disability
• Contraindication to or failure of acute treatments
• Acute medication use >2 days per week
• Uncommon migraine variants (hemiplegic migraine, prolonged aura)

Preventive Medication Options

• First-line preventive agents with proven efficacy 1:
  • Topiramate (discuss teratogenicity with women of childbearing potential)
  • Propranolol or timolol (beta-blockers)
  • Amitriptyline
  • Divalproex sodium/valproate
• Alternative options if first-line agents fail: ACE inhibitors, ARBs, or SSRIs 1
• Start preventive medications at low dose and titrate gradually until desired response achieved 1
• Allow adequate trial period: 2-3 months for oral agents, 3-6 months for CGRP monoclonal antibodies 2

Lifestyle Modifications (Essential Adjunct)

• Maintain regular sleep schedule with consistent bedtime and wake time 1, 3
• Regular meals and adequate hydration to avoid triggers 1, 3
• Moderate-to-intense aerobic exercise regularly 1, 3
• Stress management with relaxation techniques or mindfulness 1, 3

Monitoring and Follow-Up

• Use headache diary to track attack frequency, medication use, triggers, and treatment response 1
• Switch preventive therapy if inadequate response after appropriate trial period 1
• Monitor for medication overuse patterns and intervene early 1, 2

Key Contraindications and Cautions

• Triptans are contraindicated in: coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, stroke/TIA history, hemiplegic migraine, basilar migraine, Wolff-Parkinson-White syndrome 4
• Screen for cardiovascular risk factors before prescribing triptans 4
• Avoid combining triptans with ergotamines (24-hour separation required) 4
• Monitor for serotonin syndrome when combining triptans with SSRIs, SNRIs, TCAs, or MAOIs 4