What treatment options are available for a patient with typical migraine symptoms and no relevant medical history?

Treatment for Typical Migraine Symptoms in Treatment-Naive Patient

Start with NSAIDs as first-line therapy—specifically ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 900-1000 mg—taken at the first sign of headache when pain is still mild. 1, 2

First-Line Treatment Approach

For mild to moderate migraine attacks:

• Administer ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 900-1000 mg at onset 1, 2
• The combination of acetaminophen 1000 mg + aspirin 1000 mg + caffeine 130 mg is also effective 1, 2
• Acetaminophen alone (1000 mg) is significantly less effective and should only be used if NSAIDs are contraindicated 1
• Add an antiemetic (metoclopramide 10 mg or prochlorperazine 10 mg) if nausea is present, as this provides synergistic analgesia beyond just treating nausea 1, 2

Critical timing principle:

• Medication must be taken early in the attack when headache is still mild for maximum efficacy 1, 2
• Waiting until pain becomes severe significantly reduces treatment effectiveness 1

When to Escalate to Triptans

If NSAIDs fail after 2-3 consecutive attacks, escalate to triptan therapy: 1, 2

• Oral triptans with strongest evidence: sumatriptan 50-100 mg, rizatriptan 10 mg, or zolmitriptan 2.5-5 mg 1
• Triptans are most effective when taken early while headache is still mild 1
• If one triptan fails, try a different triptan before abandoning this class—failure of one does not predict failure of others 1, 2

Triptan contraindications to screen for: 1, 3

• Uncontrolled hypertension
• Coronary artery disease or cardiovascular risk factors
• Basilar or hemiplegic migraine
• History of stroke or TIA
• Wolff-Parkinson-White syndrome

Critical Medication Overuse Warning

Limit all acute medications to no more than 2 days per week (8-10 days per month maximum): 1, 2, 4

• Using acute medications more frequently causes medication-overuse headache, creating a vicious cycle of increasing headache frequency 1, 2
• This applies to NSAIDs, triptans, combination analgesics, and especially opioids 1, 2
• If the patient requires acute treatment more than twice weekly, preventive therapy must be initiated 1, 4

When to Consider Preventive Therapy

Initiate preventive therapy if any of the following apply: 1, 4

• Two or more migraine attacks per month causing disability for 3+ days
• Using acute medications more than 2 days per week
• Failure of or contraindications to acute treatments
• Patient preference to reduce attack frequency

First-line preventive options: 1, 4

• Propranolol 80-240 mg daily or other beta-blockers (metoprolol, atenolol)
• Topiramate 50-200 mg daily
• Candesartan 16 mg daily
• Amitriptyline 30-150 mg daily (especially if comorbid tension-type headache)

Medications to Avoid

Do not use opioids or butalbital-containing compounds as routine therapy: 1, 2

• These medications lead to dependency, medication-overuse headache, and loss of efficacy 1, 2
• Reserve only for rare rescue situations when all other options have failed and abuse risk has been addressed 1, 2

Practical Implementation Algorithm

1. First attack: Ibuprofen 400-600 mg or naproxen sodium 500-825 mg at onset 1, 2
2. If nausea present: Add metoclopramide 10 mg taken 20-30 minutes before NSAID 2
3. After 3 failed NSAID trials: Switch to triptan (sumatriptan 100 mg, rizatriptan 10 mg, or zolmitriptan 5 mg) 1, 2
4. If first triptan fails after 2-3 attacks: Try different triptan 1, 2
5. If using acute meds >2 days/week: Initiate preventive therapy immediately 1, 4

Common Pitfalls to Avoid

• Taking medication too late in the attack when pain is already severe reduces efficacy by 50% or more 1
• Using acetaminophen alone—it has minimal efficacy for migraine 1
• Allowing patients to increase frequency of acute medication use, which creates medication-overuse headache 1, 2
• Failing to educate about the 2-day-per-week limit for acute medications 1, 2
• Not screening for cardiovascular risk factors before prescribing triptans 1, 3