What is the first line medication for treating migraines?

First-Line Medication for Acute Migraine Treatment

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

Treatment Algorithm Based on Migraine Severity

Mild to Moderate Migraine

• Start with NSAIDs as first-line therapy: 1

  • Aspirin 500-1000 mg 1
  • Ibuprofen 400-800 mg 1
  • Naproxen sodium 500-825 mg 1
  • Combination therapy: acetaminophen + aspirin + caffeine (provides synergistic analgesia) 1

• Acetaminophen alone is ineffective and should not be used as monotherapy 2

• Escalate to triptans if NSAIDs fail after 2 hours or after 2-3 migraine episodes 1

Moderate to Severe Migraine

• Triptans are first-line therapy for moderate to severe attacks: 1, 3

  • Oral triptans with strong evidence: sumatriptan, rizatriptan, naratriptan, zolmitriptan 1
  • Standard oral sumatriptan dose: 50-100 mg 4
  • Subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours) but with higher adverse event rates 1

• For attacks with significant nausea/vomiting, use non-oral routes: 1, 2

  • Subcutaneous sumatriptan (most rapid onset) 1, 5
  • Intranasal sumatriptan 5-20 mg 1
  • Intranasal zolmitriptan 6

Adjunctive Antiemetic Therapy

• Add antiemetics even when nausea is present without vomiting: 2
  • Metoclopramide 10 mg (provides direct analgesic effects through dopamine antagonism, not just antiemetic action) 1
  • Prochlorperazine 10 mg or 25 mg 1
  • Give antiemetics 20-30 minutes before NSAIDs for synergistic analgesia 1

Critical Implementation Principles

• Take medication early in the attack while pain is still mild - this prevents central sensitization and improves efficacy 1, 6

• Limit acute treatment to no more than twice weekly to prevent medication-overuse headache 1, 2

• If headache returns after initial response, a second dose may be taken at least 2 hours after the first dose 7

• Maximum daily triptan dose should not exceed 80 mg for eletriptan or equivalent for other triptans 7

When to Consider Preventive Therapy

• Initiate preventive therapy if: 8
  • ≥2 migraine attacks per month with disability lasting ≥3 days 8
  • Using acute medications more than twice weekly 8
  • Contraindications to or failure of acute treatments 8

Common Pitfalls to Avoid

• Do not use opioids or butalbital-containing compounds as first-line therapy - they lead to dependency, rebound headaches, and loss of efficacy 1, 2

• Do not prescribe triptans for patients with: 2, 7

  • Uncontrolled hypertension
  • Coronary artery disease or risk factors without cardiovascular evaluation
  • Hemiplegic or basilar migraine
  • Recent use (within 24 hours) of ergotamines or other triptans

• Do not allow patients to increase frequency of acute medication use in response to treatment failure - instead transition to preventive therapy 1

• Avoid taking triptans too late in the attack - efficacy decreases significantly when taken after pain becomes severe 1