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 combine triptans with NSAIDs for maximum efficacy. 1

Acute Treatment Algorithm

Mild-to-Moderate Attacks (First-Line)

• Use NSAIDs as initial therapy: aspirin 500-1000 mg, ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or diclofenac potassium 50-100 mg 1, 2
• Combination therapy with acetaminophen + aspirin + caffeine is effective for mild attacks, though acetaminophen alone has limited efficacy 1, 3
• Take medication as early as possible when headache is still mild to maximize effectiveness 1, 2

Moderate-to-Severe Attacks (Triptan Strategy)

• Offer triptans when NSAIDs provide inadequate relief: sumatriptan 50-100 mg, rizatriptan 10 mg, eletriptan 40 mg, zolmitriptan 2.5-5 mg, almotriptan 12.5 mg, naratriptan 2.5 mg, or frovatriptan 2.5 mg 1, 2
• Triptans are most effective when taken early while pain is still mild 1
• If one triptan fails, try a different triptan—failure of one does not predict failure of others 1
• Combine a triptan with an NSAID for superior efficacy compared to either agent alone 1, 2

Route Selection Based on Symptoms

• For patients with significant nausea/vomiting: use non-oral routes including subcutaneous sumatriptan 6 mg (highest efficacy at 59% pain-free at 2 hours), intranasal sumatriptan 5-20 mg, or intranasal zolmitriptan 1, 2
• Add antiemetics (metoclopramide 10 mg IV/PO or prochlorperazine 10 mg IV/25 mg PO) 20-30 minutes before analgesics for synergistic pain relief and treatment of nausea 1, 2

Refractory Migraine (Third-Line)

• For patients who fail all triptans or have contraindications: use CGRP antagonists (gepants: rimegepant, ubrogepant, zavegepant), lasmiditan (ditan), or dihydroergotamine 1, 2
• Dihydroergotamine (DHE) intranasal or IV has good efficacy for refractory attacks 2

Emergency Department/Urgent Care IV Therapy

• First-line IV combination: metoclopramide 10 mg IV + ketorolac 30 mg IV provides rapid relief with minimal rebound risk 1
• Prochlorperazine 10 mg IV is equally effective to metoclopramide for headache pain relief 1, 2
• Avoid opioids—they lead to dependency, medication overuse headache, and loss of efficacy 1, 2

Critical Medication Overuse Prevention

• Limit acute medication use to prevent medication overuse headache: ≤15 days/month for NSAIDs, ≤10 days/month for triptans, ≤2 days/week overall 1, 2
• Medication overuse headache presents as daily or near-daily headaches and requires detoxification with temporary worsening before improvement 4

When to Initiate Preventive Therapy

• Start preventive medications if: ≥2 attacks per month causing ≥3 days of disability, contraindication to acute treatments, acute medication use >2 days/week, or presence of hemiplegic migraine or prolonged aura 1
• Preventive options include topiramate, propranolol, timolol, amitriptyline, or divalproex sodium 1, 3
• Monitor with headache diary to track frequency, identify overuse patterns, and assess treatment response 1

Lifestyle Modifications (Adjunctive)

• Maintain regular sleep schedule with 7-9 hours nightly 1
• Eat regular meals without skipping and stay well-hydrated 1
• Engage in moderate-to-intense aerobic exercise regularly 1
• Practice stress management with relaxation techniques or mindfulness 1

Medications to Avoid

• Never use opioids or butalbital-containing compounds routinely—they cause dependency, rebound headaches, and medication overuse headache 1, 2
• Opioids should only be reserved for rare situations where all other options are contraindicated, sedation is acceptable, and abuse risk has been addressed 2

Triptan Contraindications and Precautions

• Contraindicated in coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, history of stroke/TIA, hemiplegic migraine, and Wolff-Parkinson-White syndrome 4
• Monitor for chest/throat/jaw tightness—usually non-cardiac but requires evaluation in high-risk patients 4
• Risk of serotonin syndrome when combined with SSRIs, SNRIs, TCAs, or MAO inhibitors 4

Common Pitfalls to Avoid

• Do not delay treatment—early administration during mild pain phase dramatically improves efficacy 1, 2
• Do not use acetaminophen alone—it has inferior efficacy compared to NSAIDs or combination therapy 1, 3
• Do not allow patients to escalate acute medication frequency in response to treatment failure—this creates medication overuse headache; instead transition to preventive therapy 1
• Do not assume all triptans are equivalent for an individual patient—trial different triptans if first choice fails 1