What are the treatment options for migraines?

Migraine Treatment

Acute Treatment Algorithm

For acute migraine attacks, start with combination therapy of an NSAID plus acetaminophen (or acetaminophen/aspirin/caffeine) for mild to moderate attacks, and escalate to triptans combined with NSAIDs for moderate to severe attacks, with treatment initiated as early as possible during the attack. 1, 2

First-Line Acute Treatment

• Begin treatment immediately upon migraine onset with combination therapy rather than monotherapy for maximum efficacy 1, 2
• For mild to moderate attacks, use NSAIDs (aspirin, ibuprofen, or diclofenac potassium) combined with acetaminophen 1, 2
• Acetaminophen/aspirin/caffeine combination is an effective alternative for mild attacks 1, 2
• Acetaminophen 1000 mg as monotherapy is less effective than NSAIDs or combination therapy and should be reserved for patients intolerant of NSAIDs 1, 2

Second-Line Acute Treatment (Triptans)

• Offer triptans to patients who fail over-the-counter analgesics 1
• Triptans are most effective when taken early while headache is still mild 1
• Combine a triptan with an NSAID or acetaminophen for superior efficacy compared to either agent alone 1, 2
• If one triptan fails, trial other triptans as individual responses vary 1
• Sumatriptan demonstrates dose-dependent efficacy with 50 mg and 100 mg doses superior to 25 mg, achieving headache response (reduction to mild or no pain) in 61-62% at 2 hours and 78-79% at 4 hours versus 27% and 38% with placebo 3

Non-Oral Routes for Nausea/Vomiting

• Use non-oral triptans (subcutaneous, nasal) for patients with severe nausea or vomiting 1
• Subcutaneous sumatriptan injection achieves Cmax of 71 ng/mL compared to 51 ng/mL with oral 100 mg dose 3
• Add antiemetics (metoclopramide 10 mg or prochlorperazine) to improve gastric motility and treat nausea 1, 2

Third-Line Acute Treatment

• For patients who fail all triptans or have contraindications (coronary artery disease, uncontrolled hypertension, Wolff-Parkinson-White syndrome), escalate to CGRP antagonists (rimegepant, ubrogepant, zavegepant), dihydroergotamine, or lasmiditan 1, 2, 3
• Lasmiditan should be considered only after failure of all other pharmacologic treatments 2

Emergency/Parenteral Treatment

• For severe migraine requiring parenteral therapy, use IV ketorolac 30 mg plus IV metoclopramide 10 mg as first-line combination 2

Critical Medication Overuse Prevention

Limit acute medication use to ≤10 days per month for triptans and ≤15 days per month for NSAIDs to prevent medication overuse headache. 1, 2, 3

• Initiate preventive therapy if acute treatment is needed more than 2 days per week 1, 2
• Medication overuse headache presents as daily migraine-like headaches or marked increase in attack frequency 3

Medications to Avoid

• Never use opioids or butalbital-containing analgesics for migraine due to questionable efficacy, adverse effects, dependency risk, and contribution to medication overuse headache 1, 4

Preventive Therapy Indications

Consider preventive therapy for patients with ≥2 attacks per month producing disability lasting ≥3 days per month, contraindication to or failure of acute treatments, or use of acute medication more than twice weekly. 1

First-Line Preventive Medications

• Topiramate (requires discussion of teratogenic effects with patients of childbearing potential) 1
• Beta-blockers: metoprolol, propranolol, or timolol 1, 5
• Amitriptyline 1, 5
• Divalproex 5
• Start at low dose and gradually titrate until desired outcomes achieved 1

Chronic Migraine (≥15 headache days/month)

• OnabotulinumtoxinA 155 units is FDA-approved and specifically indicated for chronic migraine based on large-scale, double-blind, placebo-controlled trials 1
• Rule out secondary causes of headache before establishing chronic migraine diagnosis 1

Second-Line Preventive Options

• ACE inhibitors (lisinopril), ARBs (candesartan), or SSRIs if first-line treatments are not tolerated or provide inadequate response 1, 5
• Monitor treatment efficacy using a headache diary and switch preventive treatment if adequate response not achieved during reasonable trial period 1

Newer Preventive Agents

• CGRP receptor monoclonal antibodies (erenumab and related agents) are FDA-approved for migraine prevention 6

Non-Pharmacologic Treatments

• Cognitive-behavioral therapy, biofeedback, and relaxation training should be offered to all patients as part of comprehensive management 1, 5
• Regular moderate to intense aerobic exercise (40 minutes three times weekly) is as effective as some preventive medications 1

Essential Lifestyle Modifications

• Maintain regular meals and adequate hydration 1, 2
• Ensure sufficient and consistent sleep 1, 2
• Engage in regular aerobic exercise 1, 2
• Manage stress with relaxation techniques or mindfulness practices 1, 2
• Identify and reduce triggers using a headache diary 1
• Weight loss if overweight or obese 2

Special Populations

• For pregnant or breastfeeding patients, use acetaminophen as first-line treatment, with NSAIDs acceptable prior to third trimester 2

Cost Considerations

• Prescribe generic NSAIDs and older triptans when equally effective, as they are significantly less expensive than newer agents 2