What are the recommended treatments for migraine management?

Migraine Management

Acute Treatment Algorithm

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 650-1000 mg); for moderate to severe attacks, use triptans as first-line therapy, taken early when pain is still mild. 1, 2

First-Line Acute Treatment by Severity

Mild to Moderate Attacks:

• NSAIDs are the initial choice, with specific options including ibuprofen 400-800 mg every 6 hours, naproxen sodium 500-825 mg (can repeat every 2-6 hours, maximum 1.5 g/day), or aspirin 650-1000 mg every 4-6 hours 1, 3, 2
• Combination analgesics containing acetaminophen, aspirin, and caffeine are effective alternatives when NSAIDs alone provide inadequate relief 3, 2
• Critical timing principle: Treat early in the attack to maximize efficacy 1, 4

Moderate to Severe Attacks:

• Triptans are first-line therapy and must be taken early while pain is still mild for optimal effectiveness 1, 3, 2
• Oral options with strong evidence include sumatriptan, rizatriptan, naratriptan, zolmitriptan, almotriptan, and eletriptan 1, 2, 5
• For rapid onset or when nausea/vomiting is present, use non-oral formulations: subcutaneous sumatriptan 6 mg (59% complete pain relief at 2 hours), intranasal sumatriptan 5-20 mg, or intranasal zolmitriptan 1, 2, 4

Adjunctive Antiemetic Therapy

• Add metoclopramide 10 mg or prochlorperazine 10-25 mg for nausea, which provides synergistic analgesia beyond just treating nausea 3, 2
• Antiemetics should be given 20-30 minutes before analgesics to enhance absorption and efficacy 2
• Important caveat: Nausea itself is one of the most disabling migraine symptoms and warrants treatment even without vomiting 2

Second-Line and Rescue Options

• If triptans fail, try a different triptan before abandoning the class entirely, as failure of one does not predict failure of others 2
• Consider combination therapy: triptan plus fast-acting NSAID to prevent the 40% recurrence rate within 48 hours 2
• Intranasal dihydroergotamine (DHE) is effective for patients with contraindications to triptans 3, 2
• Opioids should be avoided due to risk of medication overuse headache, dependency, and limited efficacy evidence; reserve only for cases where other medications cannot be used and abuse risk has been addressed 1, 3, 2

Emergency/IV Treatment Protocol

For severe attacks requiring parenteral therapy:

• First-line IV combination: metoclopramide 10 mg IV plus ketorolac 30 mg IV provides rapid relief with minimal rebound risk 2
• Alternative: prochlorperazine 10 mg IV (comparable efficacy to metoclopramide with 21% adverse event rate vs 50% for chlorpromazine) 2
• Dihydroergotamine IV can be used for refractory cases 3, 2

Preventive Treatment Algorithm

Initiate preventive therapy when patients experience frequent debilitating headaches despite adequate acute treatment, or when acute medications are used more than 2 days per week. 1, 2

When to Start Prevention

• Specific indications: Severe debilitating headaches despite adequate acute treatment, contraindications to acute treatment, or acute medication use exceeding twice weekly 1
• No rigid frequency threshold exists, but consider prevention when migraine significantly impacts quality of life 1
• Patients using acute medications more than twice weekly are at high risk for medication overuse headache and require preventive therapy 1, 2

First-Line Preventive Options (Cost-Prioritized)

The American College of Physicians prioritizes cost as a key factor given similar net benefits across recommended treatments: 1

• Beta-blockers (propranolol, metoprolol) 1
• Tricyclic antidepressants (amitriptyline, especially when combined with cognitive behavioral therapy) 1, 3
• Anticonvulsants: topiramate (first-line for chronic migraine due to lower cost) or valproic acid 1, 3

Critical warnings:

• Topiramate and valproate are teratogenic; patients of childbearing potential must use effective contraception and take folate supplementation 1
• Discuss adverse effects during pregnancy and lactation with all patients of childbearing potential 1

Second-Line Preventive Options

• ACE inhibitors (lisinopril) or ARBs (candesartan, telmisartan) if first-line agents are not tolerated 1
• SSRIs (fluoxetine) for select patients 1

Third-Line Preventive Options

• OnabotulinumtoxinA for patients who have failed other preventive medications, particularly for chronic migraine 3
• CGRP monoclonal antibodies for refractory cases 3

Preventive Treatment Principles

• Start low and titrate gradually until desired outcomes are achieved 1
• Allow adequate trial period: 2-3 months for oral agents, 3-6 months for CGRP antibodies, 6-9 months for onabotulinumtoxinA before declaring failure 1, 2
• Switch medications if inadequate response after reasonable trial or if adverse effects occur 1
• Emphasize that improvement occurs gradually; effects may not be apparent for several weeks 1

Critical Management Principles

Medication Overuse Headache Prevention

The single most important avoidable cause of headache disability is medication overuse headache from frequent acute treatment use. 5

• Strict frequency limit: Use acute medications no more than 2 days per week 1, 2
• Medication overuse headache develops when acute medications are used more than twice weekly, leading to daily headaches 3, 2
• If overuse is occurring, transition to preventive therapy immediately while optimizing acute treatment strategy 2

Lifestyle and Trigger Management

• Before initiating pharmacologic prevention, explore modifiable triggers and contributing factors 1
• Emphasize hydration, regular adequate sleep, and regular physical activity 1
• Identify and manage specific triggers including environmental factors, dietary triggers, stress, and hormonal changes 6
• Behavioral interventions (cognitive behavioral therapy, relaxation training, mindfulness) decrease migraine frequency and should be combined with pharmacologic treatment 1, 6

Monitoring and Follow-Up

• Use a headache diary to determine treatment efficacy, identify analgesic overuse, and monitor for progression to chronic migraine 1
• Evaluate adequacy of acute treatment strength and appropriateness before adding prevention 1
• Periodically reevaluate the balance of benefits, harms, and costs of preventive treatment 1

Special Populations

Pediatric and Adolescent Patients:

• For acute treatment: ibuprofen is first-line; in adolescents consider sumatriptan/naproxen combination, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral 1
• For prevention: discuss with families that placebo was as effective as studied medications in many pediatric trials 1
• Evidence supports amitriptyline combined with cognitive behavioral therapy, topiramate, and propranolol 1

Patients of Childbearing Potential:

• Discuss adverse effects of all pharmacologic treatments during pregnancy and lactation before initiating therapy 1
• Avoid topiramate and valproate unless effective contraception is ensured 1

Common Pitfalls to Avoid

• Do not delay triptan administration—they are most effective when taken early while pain is mild, not after pain becomes severe 2, 4
• Do not allow patients to increase acute medication frequency in response to treatment failure; this creates medication overuse headache 2
• Do not use opioids or barbiturates routinely—they cause dependency, rebound headaches, and have limited efficacy evidence 3, 2
• Do not abandon triptans after one failure—try different triptans, different routes, or combination with NSAIDs before escalating 2
• Do not forget to address comorbidities including depression, sleep disturbances, obesity, and cardiovascular risk factors, which impact treatment selection 3