What are the treatment options for migraines?

Migraine Treatment

For acute migraine treatment, start with NSAIDs (aspirin, ibuprofen, naproxen, or diclofenac) plus an antiemetic for mild-to-moderate attacks, and escalate to triptans for moderate-to-severe attacks or when NSAIDs fail after three consecutive attempts. 1, 2

Acute Treatment Algorithm

First-Line: NSAIDs + Antiemetic

• Use NSAIDs as initial therapy for most patients with mild-to-moderate migraine attacks 1, 2
• Specific NSAIDs with strongest evidence: aspirin 900-1000mg, ibuprofen 400-800mg, naproxen sodium 500-825mg, or diclofenac potassium 50-100mg 1, 2, 3
• Add an antiemetic (metoclopramide 10mg or prochlorperazine 10mg) even if nausea is not prominent, as these provide synergistic analgesia and improve gastric motility 1, 2, 3
• The aspirin-acetaminophen-caffeine combination (250mg/250mg/65mg) is highly effective with a number needed to treat of 4 for pain relief at 2 hours 2
• Acetaminophen alone is ineffective and should not be used as monotherapy 1

Second-Line: Triptans

• Escalate to triptans after three consecutive attacks fail to respond adequately to NSAIDs 1, 2
• Triptans are first-line for moderate-to-severe attacks from the outset 1, 2, 4
• Administer triptans early in the attack while pain is still mild for maximum effectiveness 2, 4, 5
• Oral triptans with strongest evidence: sumatriptan 50-100mg, rizatriptan 10mg, zolmitriptan 2.5-5mg, naratriptan 2.5mg 1, 5
• Combining a triptan with an NSAID improves efficacy beyond either agent alone 2, 4
• Sumatriptan 50mg or 100mg provides headache response in 61-62% at 2 hours and 78-79% at 4 hours, compared to 27% and 38% with placebo 5

Critical triptan prescribing principles:

• If one triptan fails, try a different triptan—failure of one does not predict failure of others 1, 2
• Maximum of two doses in 24 hours; do not exceed 5
• Contraindicated in uncontrolled hypertension, coronary artery disease, Wolff-Parkinson-White syndrome, basilar or hemiplegic migraine, and previous stroke/TIA 1, 5

Third-Line: CGRP Antagonists (Gepants) or Ditans

• For patients who fail all available triptans or have cardiovascular contraindications to triptans, use gepants (rimegepant 75mg, ubrogepant 50-100mg, or zavegepant nasal spray) 1, 2
• Lasmiditan (ditan) 50-100mg is an alternative but causes significant sedation and requires 8-hour driving restriction 2
• Ubrogepant and rimegepant have a number needed to treat of 13 for pain freedom at 2 hours 2

Alternative Routes for Severe Nausea/Vomiting

• Subcutaneous sumatriptan 6mg provides the highest efficacy (59% pain-free at 2 hours) and fastest onset (15 minutes) 3, 4
• Intranasal sumatriptan 20mg or zolmitriptan 5mg for patients unable to tolerate oral medications 1, 3
• Intranasal DHE has good evidence for efficacy and safety 1, 3

Rescue Therapy for Refractory Attacks

• IV metoclopramide 10mg plus IV ketorolac 30mg is the preferred emergency department combination 3
• IV prochlorperazine 10mg is equally effective to metoclopramide with comparable side effect profile 3
• Avoid opioids and butalbital-containing compounds—these lead to medication overuse headache, dependency, and loss of efficacy 1, 2, 3

Preventive Treatment Indications

Consider preventive therapy when patients experience ≥2 migraine days per month with significant disability despite optimized acute treatment, or when acute medications are used more than twice weekly 1, 2, 4

First-Line Preventive Medications

• Beta-blockers: propranolol 80-240mg daily, metoprolol 100-200mg daily, atenolol 50-100mg daily, or bisoprolol 5-10mg daily 1
• Topiramate 50-200mg daily (requires teratogenicity counseling for women of childbearing potential) 1, 2
• Candesartan 16mg daily 1

Second-Line Preventive Medications

• Amitriptyline 25-150mg nightly 1
• Flunarizine 5-10mg daily 1
• Sodium valproate 500-1500mg daily (strictly contraindicated in women of childbearing potential) 1

Third-Line: CGRP Monoclonal Antibodies

• Erenumab, fremanezumab, galcanezumab, or eptinezumab for patients who fail or cannot tolerate first- and second-line preventive medications 1
• OnabotulinumtoxinA 155 units every 12 weeks specifically for chronic migraine (≥15 headache days per month) 2

Non-Pharmacologic Interventions

Recommend lifestyle modifications as foundational therapy for all patients:

• Maintain regular meal schedule and adequate hydration 2, 4
• Ensure consistent sleep schedule with 7-8 hours nightly 2, 4
• Engage in regular moderate-to-intense aerobic exercise 40 minutes three times weekly—this is as effective as some preventive medications 2
• Practice stress management with relaxation techniques or mindfulness 2, 4

Evidence-based behavioral therapies:

• Cognitive-behavioral therapy, biofeedback, and relaxation training should be offered to all patients as adjuncts or stand-alone preventive treatment 1, 2
• Remote electrical neuromodulation devices have evidence for acute treatment 1
• Acupuncture may provide benefit, though not superior to sham acupuncture 1

Critical Medication Overuse Headache Prevention

Limit acute medication use to prevent medication overuse headache:

• NSAIDs: ≤15 days per month 2
• Triptans: ≤10 days per month 2, 5
• Total acute medication use should not exceed twice weekly 1, 2
• Medication overuse headache presents as daily or near-daily headaches with marked increase in attack frequency 5

If medication overuse is suspected, transition to preventive therapy immediately while limiting acute medication use 1, 2

Special Population Considerations

Older Adults

• Triptans can be used cautiously with regular blood pressure monitoring, despite theoretical cardiovascular concerns 1
• Monitor for comorbidities and drug interactions more carefully 1

Pregnancy and Lactation

• Acetaminophen is the safest option during pregnancy 6
• Sumatriptan may be considered for selected patients during pregnancy and is compatible with breastfeeding 6
• Avoid NSAIDs in third trimester 6

Children and Adolescents

• Migraine attack duration can be 2-72 hours (shorter than adult criteria) 1
• Treatment principles similar to adults but with weight-based dosing 1

Monitoring and Follow-Up

Have patients maintain a headache diary tracking:

• Severity, frequency, and duration of attacks 1, 4
• Degree of disability from attacks 1, 4
• Response to treatment and adverse effects 1, 4
• Trigger identification (alcohol, caffeine, tyramine-containing foods, stress, sleep deprivation) 1, 4

Reassess treatment strategy if inadequate response after 2-3 attacks with a given medication 1, 2