What are the treatment options for migraines?

Migraine Treatment

Acute Treatment Strategy

For mild to moderate migraine attacks, start with combination therapy of NSAID plus acetaminophen or the combination of acetaminophen/aspirin/caffeine; for moderate to severe attacks that fail initial therapy, escalate to a triptan combined with an NSAID. 1, 2

First-Line Acute Treatment

• Aspirin-acetaminophen-caffeine combination is strongly recommended as first-line therapy for mild to moderate attacks, with a number needed to treat of 9 for pain freedom at 2 hours and 4 for pain relief at 2 hours. 3
• NSAIDs with proven efficacy include aspirin, ibuprofen, naproxen sodium, and diclofenac potassium. 1
• Acetaminophen 1000 mg can be used as monotherapy but is less effective than NSAIDs or combination therapy. 2
• Early administration of treatment significantly improves efficacy—patients should begin treatment as soon as possible after migraine onset. 1, 2

Second-Line Acute Treatment: Triptans

• Triptans should be offered to patients for whom over-the-counter analgesics provide inadequate headache relief. 1
• Combining a triptan with an NSAID or acetaminophen improves efficacy compared to either agent alone. 1
• Triptans are most effective when taken early in an attack while headache is still mild. 1
• Oral sumatriptan 50 mg provides pain-free response in 28% versus 11% with placebo (NNT 6.1), while the 100 mg dose achieves pain-free response in approximately 30% versus 11% with placebo (NNT 4.7). 4
• If one triptan is ineffective, others might still provide relief—trial different triptans before abandoning this class. 1
• For patients who cannot take oral medications due to vomiting, subcutaneous sumatriptan injection is highly effective, providing pain-free response in 59% versus 15% with placebo (NNT 2.3). 5

Third-Line Acute Treatment: Advanced Options

• For patients who fail all available triptans or have contraindications to triptans, options include CGRP antagonists (gepants) like rimegepant and ubrogepant, dihydroergotamine, or lasmiditan. 1
• Ubrogepant and rimegepant receive a weak recommendation with a number needed to treat of 13 for pain freedom at 2 hours. 3
• Lasmiditan demonstrated robust benefit for pain freedom at 2 hours but has significant adverse effects including driving restrictions and a number needed to harm of 4 for treatment-emergent adverse effects; it should be considered only after failure of all other pharmacologic treatments. 3, 2

Managing Associated Symptoms

• Use non-oral routes of administration (subcutaneous, intranasal, rectal) for patients with migraine accompanied by nausea/vomiting. 1
• For severe migraine requiring parenteral therapy in emergency settings, IV ketorolac 30 mg plus IV metoclopramide 10 mg is recommended as first-line combination therapy. 2
• Antiemetics like metoclopramide or prochlorperazine treat accompanying nausea and improve gastric motility. 1

Critical Treatment Cautions

• Avoid opioids and butalbital-containing analgesics for migraine treatment—these are explicitly not recommended. 1, 2, 6
• Limit acute medication use to prevent medication overuse headache: ≤10 days per month for triptans, ≤15 days per month for NSAIDs. 2, 7, 8
• Medication overuse headache may present as migraine-like daily headaches or marked increase in migraine frequency; detoxification including withdrawal of overused drugs may be necessary. 7, 8
• Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's variant angina, uncontrolled hypertension, history of stroke or TIA, and Wolff-Parkinson-White syndrome. 7, 8
• Monitor for serotonin syndrome when triptans are co-administered with SSRIs, SNRIs, TCAs, or MAO inhibitors. 7, 8

Preventive Treatment Indications

Consider preventive therapy for patients with: two or more attacks per month producing disability lasting 3+ days per month; contraindication to or failure of acute treatments; use of acute medication more than twice per week; or presence of uncommon migraine conditions. 1

Preventive Medication Options

• First-line preventive options include beta-blockers, topiramate, or candesartan. 6
• Topiramate is effective for preventive treatment but requires discussion of teratogenic effects with patients of childbearing potential. 1
• Consider an ACE inhibitor, ARB, or SSRI if first-line treatments are not tolerated or result in inadequate response. 1
• For chronic migraine (≥15 headache days per month), onabotulinumtoxinA 155 units is FDA-approved and effective based on large-scale, double-blind, placebo-controlled trials. 1
• Start preventive medications at a low dose and gradually increase until desired outcomes are achieved. 1
• Monitor treatment using a headache diary to determine treatment efficacy, identify analgesic overuse, and follow up on migraine progression. 1

Non-Pharmacologic Preventive Treatments

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

Essential Lifestyle Modifications

• Maintain regular meals, stay well hydrated, and ensure sufficient and consistent sleep. 1, 2
• Engage in regular physical activity, preferably moderate to intense aerobic exercise. 1
• Manage stress with relaxation techniques or mindfulness practices. 1, 6
• Address predisposing factors such as poor sleep quality, poor physical fitness, or stress. 1
• Identify and reduce aggravating factors and triggers using a headache diary. 1
• Weight loss if overweight is recommended. 2

Special Population Considerations

• For pregnant or breastfeeding patients, acetaminophen is first-line treatment, with NSAIDs usable prior to the third trimester. 2
• Prescribe less costly recommended medications when equally effective options exist—generic NSAIDs and older triptans are significantly less expensive than newer agents. 2