What medications are used to treat migraine?

Medications for Migraine Treatment

For acute migraine attacks, NSAIDs (aspirin, ibuprofen, naproxen sodium) are first-line treatment for mild to moderate attacks, while triptans are first-line for moderate to severe attacks. 1, 2

Acute Treatment Algorithm

Mild to Moderate Migraine

• Start with NSAIDs as first-line therapy 1, 2
• Specific NSAIDs with strong evidence include:
  • Aspirin 900-1000 mg 2, 3
  • Ibuprofen 400-800 mg 2, 3
  • Naproxen sodium 500-825 mg 2
  • Combination acetaminophen-aspirin-caffeine 1, 2
• Acetaminophen alone is ineffective for migraine 1, 4

Moderate to Severe Migraine

• Triptans are first-line therapy when NSAIDs fail or for severe attacks 1, 2, 5
• Oral triptans with strong evidence:
  • Sumatriptan 50-100 mg (most commonly used) 2, 6, 7
  • Rizatriptan 1, 2
  • Zolmitriptan 1, 2
  • Naratriptan 1, 2
• The 50 mg dose of sumatriptan offers the best balance of efficacy and tolerability, though many patients require 100 mg 8
• Take triptans early in the attack when pain is still mild for maximum effectiveness 2, 5

Route Selection Based on Symptoms

• When nausea or vomiting is present, use non-oral routes 1, 2, 4
  • Subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours) but more adverse events 7
  • Intranasal sumatriptan 5-20 mg or zolmitriptan 2, 9
  • Rectal sumatriptan 25 mg 7
• Add antiemetics (metoclopramide 10 mg IV or prochlorperazine 10 mg IV) for nausea, which also provide synergistic analgesia 2, 4

Second-Line and Rescue Options

When First-Line Fails

• Dihydroergotamine (DHE) intranasal or IV 0.5-1.0 mg has good evidence for efficacy 1, 2, 4
• Combination therapy: triptan plus NSAID provides better efficacy than either alone 2, 10
• If one triptan fails, try a different triptan before abandoning the class 2

Rescue Medications (Last Resort Only)

• Opioids (including butorphanol nasal spray) should only be used when other medications cannot be used, sedation is not a concern, and abuse risk has been addressed 1, 2
• Avoid opioids, butalbital compounds, and ergotamine due to dependency risk and rebound headaches 1, 2, 4

Critical Contraindications and Precautions

Triptan Contraindications

• Do not use triptans in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or cardiovascular disease 1, 2, 4
• Do not combine triptans with ergotamines 4, 11
• Do not use triptans with MAO inhibitors 6

Medication-Overuse Headache Prevention

• Limit acute treatment to no more than twice weekly (maximum 10 days per month) to prevent medication-overuse headache 1, 2, 4, 10
• If using acute medications more frequently, initiate preventive therapy 1, 2

Preventive Therapy Indications

Consider preventive therapy when: 1

• Two or more migraine attacks per month producing disability for three or more days
• Acute medication use exceeds twice weekly
• Acute treatments are ineffective or contraindicated

First-line preventive agents include: 3

• Beta blockers (propranolol) 3
• Antidepressants (amitriptyline 30-150 mg/day) 3
• Anticonvulsants (divalproex sodium 500-1500 mg/day) 3

Emergency Department Protocol

For severe migraine in the ED: 2, 4

• IV metoclopramide 10 mg plus IV ketorolac 30 mg is first-line combination therapy 2
• Subcutaneous sumatriptan 6 mg provides most rapid onset 4, 7
• IV DHE 0.5-1.0 mg for refractory cases 2, 4
• Avoid oral ergot alkaloids, opioids, and barbiturates in the ED setting 4

Common Pitfalls to Avoid

• Do not wait until pain is severe to take medication—early treatment is more effective 2, 5
• Do not use acetaminophen alone—it is ineffective for migraine 1, 4
• Do not establish patterns of frequent opioid use—this leads to medication-overuse headache and dependency 1, 2
• Do not restrict antiemetics only to vomiting patients—nausea itself is disabling and warrants treatment 2
• Do not exceed maximum daily sumatriptan dose of 200 mg 6