What are the treatment options for migraine?

Migraine Treatment

For acute migraine, start with NSAIDs (aspirin, ibuprofen, naproxen, or diclofenac) for mild-to-moderate attacks, and escalate to triptans for moderate-to-severe attacks or when NSAIDs fail—combining a triptan with an NSAID provides superior efficacy to either agent alone. 1, 2

Acute Treatment Algorithm

Mild-to-Moderate Attacks

• First-line: NSAIDs with proven efficacy include aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 3
• Paracetamol (acetaminophen) has inferior efficacy and should only be used when NSAIDs are contraindicated 1
• Combination analgesics containing caffeine (aspirin + acetaminophen + caffeine) can be effective for mild attacks 1, 2
• Dosing example for naproxen: 500-825 mg at onset, repeat every 2-6 hours as needed (maximum 1.5 g/day) 2

Moderate-to-Severe Attacks

• First-line: Triptans, with or without NSAIDs 1, 2, 3
• Critical timing principle: Administer triptans early in the attack while headache is still mild for maximum effectiveness 1, 3
• Combination therapy: Triptan + NSAID provides synergistic benefit superior to either agent alone 1, 3
• Oral triptan options with strong evidence: sumatriptan 50-100 mg, rizatriptan, naratriptan, zolmitriptan 2
• If one triptan fails, try a different triptan—failure of one does not predict failure of others 1, 2

Non-Oral Routes for Nausea/Vomiting

• Subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours) but with higher adverse event rates 2
• Intranasal sumatriptan 5-20 mg or nasal spray triptans 2
• Intranasal dihydroergotamine (DHE) has good evidence for efficacy and safety 2

Managing Associated Symptoms

• Antiemetics (metoclopramide 10 mg IV or prochlorperazine 10 mg IV) provide synergistic analgesia beyond treating nausea alone 1, 2
• Add antiemetic 20-30 minutes before NSAID for improved outcomes 2

Advanced/Rescue Treatment Options

Third-Line Agents (When Triptans Fail or Are Contraindicated)

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 1
• Lasmiditan (ditan) 1
• Dihydroergotamine (DHE) 1, 2

Intravenous Treatment for Severe Attacks

• Preferred IV combination: Metoclopramide 10 mg IV + ketorolac 30 mg IV provides rapid relief with minimal rebound risk 2
• Prochlorperazine 10 mg IV is comparable to metoclopramide in efficacy 2
• Ketorolac has 6-hour duration with minimal medication overuse headache risk 2

Critical Pitfalls to Avoid

Medication Overuse Headache (MOH)

• Limit acute medication use: ≤15 days/month for NSAIDs, ≤10 days/month for triptans 1
• Avoid entirely: Opioids and butalbital-containing analgesics—these lead to dependency, rebound headaches, and loss of efficacy 1, 2
• If using acute medications >2 days/week, transition to preventive therapy 2, 3

Triptan Safety Considerations

• Contraindicated in: coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, history of stroke/TIA, Wolff-Parkinson-White syndrome 4
• Monitor for chest/throat/neck/jaw tightness—perform cardiac evaluation if high cardiac risk 4
• Risk of serotonin syndrome when combined with SSRIs, SNRIs, TCAs, or MAO inhibitors 4

Preventive Treatment Indications

Consider preventive therapy when: 1, 3

• ≥2 attacks per month producing disability lasting ≥3 days/month
• Contraindication to or failure of acute treatments
• Acute medication use >2 days/week
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura)

First-Line Preventive Options

• Beta-blockers, topiramate (discuss teratogenic effects with women of childbearing potential), or candesartan 1, 3
• ACE inhibitors, ARBs, or SSRIs if first-line agents not tolerated 1
• Start at low dose and titrate gradually; allow 2-3 months for oral agents to demonstrate efficacy 2

Lifestyle Modifications

Essential non-pharmacologic interventions: 1, 3

• Maintain regular meal schedule and adequate hydration
• Ensure consistent sleep schedule with sufficient sleep duration
• Engage in regular moderate-to-intense aerobic exercise
• Implement stress management (relaxation techniques, mindfulness, cognitive-behavioral therapy)

Monitoring Strategy

• Headache diary: Track severity, frequency, duration, disability, treatment response, and adverse effects 3
• Use diary to identify medication overuse patterns and assess treatment efficacy 1, 3
• Switch preventive treatment if inadequate response after reasonable trial period 1