What medications can I use to treat migraines?

Medications for Migraine Treatment

For acute migraine treatment, use NSAIDs (ibuprofen 400 mg, naproxen 500-825 mg, or aspirin) as first-line therapy for mild-to-moderate attacks, and triptans (sumatriptan 50-100 mg, rizatriptan, or zolmitriptan) as first-line therapy for moderate-to-severe attacks. 1

Acute Treatment Options by Severity

Mild to Moderate Migraine

• NSAIDs are your first choice: ibuprofen 400 mg, naproxen sodium 500-825 mg, or aspirin provide effective relief with favorable tolerability 1
• Ibuprofen 400 mg achieves 2-hour headache relief in 57% of patients (versus 25% with placebo), with an NNT of 3.2 1
• Naproxen should be taken at migraine onset (ideally when pain is still mild) and can be repeated every 2-6 hours as needed, maximum 1.5 g per day 1
• Combination therapy with acetaminophen + aspirin + caffeine is effective when NSAIDs alone provide inadequate relief 1

Moderate to Severe Migraine

• Triptans are first-line: oral sumatriptan 50-100 mg, rizatriptan, naratriptan, or zolmitriptan 1, 2
• Sumatriptan 50 mg achieves 2-hour headache relief in 50-61% of patients and 4-hour relief in 68-78% 2
• The 100 mg dose provides similar efficacy to 50 mg but may have more adverse effects 2
• If headache persists or returns after 2 hours, a second dose may be taken (minimum 2-hour interval), with maximum daily dose of 200 mg 2
• For patients with significant nausea/vomiting: use intranasal sumatriptan (5-20 mg) or subcutaneous sumatriptan 6 mg (59% complete pain relief at 2 hours) 1

Adding Antiemetics for Synergistic Effect

• Metoclopramide 10 mg or prochlorperazine 10 mg/25 mg given 20-30 minutes before NSAIDs provides synergistic analgesia beyond just treating nausea 1
• These antiemetics are effective even when vomiting is not present, as nausea itself is highly disabling 1

Alternative Acute Treatments (When NSAIDs/Triptans Contraindicated)

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant for moderate-to-severe attacks 3
• Dihydroergotamine (DHE): intranasal formulation has good efficacy and safety evidence 1, 3
• Lasmiditan (ditan): for moderate-to-severe attacks when other options fail 3

Intravenous Treatment for Severe/Refractory Migraine

• First-line IV combination: metoclopramide 10 mg IV + ketorolac 30 mg IV provides rapid relief with minimal rebound risk 1
• Ketorolac has 6-hour duration and minimal medication-overuse headache risk 1
• Prochlorperazine 10 mg IV is equally effective to metoclopramide with a more favorable side effect profile (21% vs 50% adverse events) 1

Preventive Therapy Indications

• Start preventive therapy if: ≥2 migraine attacks per month with ≥3 days of disability, or using acute medications more than twice weekly 4
• First-line preventive medications: propranolol 80-240 mg/day, timolol 20-30 mg/day, topiramate 100 mg/day (50 mg twice daily), or candesartan 4, 5
• Allow 2-3 months for adequate trial before determining efficacy 4

Critical Pitfalls to Avoid

• Medication-overuse headache: limit acute therapy to no more than twice weekly to prevent this vicious cycle 1, 4
• Avoid opioids and butalbital compounds for routine migraine treatment—they cause dependency, rebound headaches, and loss of efficacy 1, 3
• Start triptans early in the attack while pain is still mild for maximum efficacy 1
• Don't use propranolol for acute attacks—it is FDA-approved only for migraine prophylaxis, not for treating an attack that has already started 5

Treatment Algorithm Summary

1. Mild-moderate attack: Start with ibuprofen 400 mg or naproxen 500-825 mg 1
2. Add antiemetic: Consider metoclopramide 10 mg or prochlorperazine 25 mg given 20-30 minutes before NSAID for enhanced effect 1
3. Moderate-severe attack or NSAID failure: Use triptan (sumatriptan 50-100 mg preferred) 1, 2
4. Severe/refractory or significant vomiting: IV metoclopramide 10 mg + ketorolac 30 mg 1
5. Frequent attacks (>2/week): Initiate preventive therapy with propranolol, topiramate, or candesartan 4