First-Line Treatment for Regular Migraines
For mild to moderate migraine attacks, NSAIDs (specifically aspirin, ibuprofen, naproxen, or diclofenac) are the first-line treatment, while triptans are first-line for moderate to severe attacks. 1, 2
Acute Treatment Algorithm
Mild to Moderate Attacks
Start with over-the-counter NSAIDs as your initial approach: 1
- Ibuprofen 400 mg provides 2-hour headache relief in 57% of patients (versus 25% with placebo), with a number needed to treat (NNT) of 3.2 3
- Naproxen sodium 500-825 mg at migraine onset, ideally when pain is still mild 2
- Aspirin 900-1000 mg has strong evidence for efficacy 1, 2
- Diclofenac potassium is also supported by strong evidence 1
Acetaminophen 1000 mg has less efficacy than NSAIDs and should only be used in patients intolerant of NSAIDs 1
Moderate to Severe Attacks
Escalate to triptans when NSAIDs provide inadequate relief: 1, 2
- Oral triptans (sumatriptan 50-100 mg, rizatriptan, naratriptan, or zolmitriptan) are most effective when taken early in the attack while headache is still mild 1, 2
- The 50 mg and 100 mg doses of sumatriptan provide greater effect than 25 mg, though 100 mg may not be superior to 50 mg 4
- If one triptan fails, try another — failure of one triptan does not predict failure of others 1, 2
- Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% pain-free at 2 hours) for patients who rapidly reach peak intensity or have vomiting 2
Adjunctive Therapy
Add an antiemetic 20-30 minutes before your primary medication: 2
- Metoclopramide 10 mg provides synergistic analgesia beyond just treating nausea through central dopamine receptor antagonism 2
- Prochlorperazine 10 mg is equally effective and has a more favorable side effect profile than chlorpromazine 2
Critical Pitfalls to Avoid
Limit acute medication use to no more than 2 days per week to prevent medication-overuse headache, which can transform episodic migraine into chronic daily headache 1, 2, 5
Do not use opioids — they lead to dependency, rebound headaches, and eventual loss of efficacy 2, 6
Take medication early in the attack when pain is still mild, as this significantly improves efficacy for both NSAIDs and triptans 1, 2
When to Initiate Preventive Therapy
Consider preventive therapy if you experience ≥2 migraine attacks per month with disability lasting ≥3 days per month, or if using acute medications more than twice weekly: 7