What are the treatment options for migraine without aura?

Treatment of Migraine Without Aura

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen, naproxen, or aspirin) or combination therapy (acetaminophen + aspirin + caffeine); for moderate to severe attacks that fail NSAIDs, add a triptan to the NSAID regimen. 1

First-Line Treatment Algorithm

Mild to Moderate Attacks

• NSAIDs are the recommended first-line therapy, with strong evidence supporting aspirin, ibuprofen, naproxen sodium, and diclofenac 1, 2
• Naproxen sodium should be dosed at 500-825 mg 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) 2
• Combination therapy with acetaminophen 1000 mg + aspirin + caffeine is highly effective and represents an alternative first-line option for patients who respond poorly to NSAIDs alone 1, 2
• Acetaminophen 1000 mg alone has demonstrated efficacy but is less effective than NSAIDs or combination therapy 2

Moderate to Severe Attacks

• When NSAIDs provide inadequate relief, the American College of Physicians strongly recommends adding a triptan to the NSAID rather than switching to triptan monotherapy 1
• If acetaminophen was used initially and failed, add a triptan to acetaminophen (though this is a conditional recommendation with lower-quality evidence) 1
• Oral triptans with strong evidence include naratriptan, rizatriptan, sumatriptan, and zolmitriptan 2
• Administer triptans early in the attack while pain is still mild to maximize efficacy 2

Route Selection Based on Symptoms

• For patients with significant nausea or vomiting, use non-oral routes: intranasal sumatriptan (5-20 mg) or subcutaneous sumatriptan (6 mg) 2
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% complete pain relief at 2 hours) but has higher adverse event rates 2
• Oral triptans are appropriate when nausea is absent or mild 2

Adjunctive Antiemetic Therapy

• Add metoclopramide 10 mg or prochlorperazine 25 mg administered 20-30 minutes before the primary analgesic to provide synergistic analgesia and improve outcomes, not just for nausea control 2
• Metoclopramide should not be restricted only to patients who are vomiting, as nausea itself is one of the most disabling symptoms 2

Dosing Considerations for Triptans

• Eletriptan: 20-40 mg orally; if headache persists or returns after 2 hours, a second dose may be given (maximum 80 mg daily) 3
• A 40 mg dose of eletriptan is more effective than 20 mg 3
• Do not use triptans within 24 hours of ergotamine-containing medications or other triptans 3
• Avoid triptans within 72 hours of potent CYP3A4 inhibitors (ketoconazole, itraconazole, clarithromycin, ritonavir) 3

Critical Medication-Overuse Headache Prevention

• Limit acute medication use to no more than 2 days per week (or 10 days per month maximum) to prevent medication-overuse headache 1, 2
• This applies to all acute treatments: NSAIDs, triptans, combination analgesics, and antiemetics 2
• If patients require acute treatment more than twice weekly, transition to preventive therapy rather than increasing acute medication frequency 2

Medications to Avoid

• Opioids should be avoided as they lead to dependency, rebound headaches, and loss of efficacy 2
• Barbiturate-containing compounds (butalbital) should be avoided due to high risk of medication-overuse headache 2
• Oral ergot alkaloids have questionable efficacy and significant adverse effects 4
• Dexamethasone and corticosteroids are not supported for routine acute migraine treatment 4

Contraindications Requiring Immediate Attention

• Triptans are absolutely contraindicated in patients with ischemic coronary artery disease, history of stroke/TIA, uncontrolled hypertension, peripheral vascular disease, or hemiplegic/basilar migraine 3
• Screen for cardiovascular risk factors (age >40 in men, postmenopausal women, hypertension, hyperlipidemia, diabetes, smoking, family history) before prescribing triptans 3
• NSAIDs should be avoided in patients with renal impairment (CrCl <30 mL/min), active GI bleeding, or aspirin-induced asthma 2

When Treatment Fails

• If one triptan fails after adequate trials, try a different triptan before escalating to third-line agents, as failure of one does not predict failure of others 2
• Consider combination therapy with fast-acting NSAIDs if not already implemented 2
• Try route change (e.g., subcutaneous instead of oral) for patients who rapidly reach peak intensity 2
• Rule out medication-overuse headache if using acute medications more than twice weekly 2

Safety Monitoring

• Warn patients about serotonin syndrome risk when combining triptans with SSRIs or SNRIs: symptoms include mental status changes, agitation, hallucinations, fast heartbeat, high body temperature, tight muscles, nausea, vomiting, or diarrhea 3
• Educate patients to seek emergency care for chest discomfort, shortness of breath, or symptoms suggesting myocardial infarction 3
• The safety of treating more than 3 migraine attacks per 30-day period has not been established for triptans 3