What is the initial treatment for migraines?

Initial Treatment of Migraines

For mild to moderate migraines, start with NSAIDs (ibuprofen 400-800mg, naproxen sodium 500-825mg, or aspirin) as first-line therapy; for moderate to severe migraines, use triptans (sumatriptan 50-100mg orally or 6mg subcutaneously) as first-line treatment. 1, 2

Stratified Treatment Approach by Severity

Mild to Moderate Migraines

• NSAIDs are the first-line choice due to demonstrated efficacy and favorable tolerability 1
• Specific options with strong evidence include:
  • Ibuprofen 400-800mg 1
  • Naproxen sodium 500-825mg (can repeat every 2-6 hours, maximum 1.5g/day) 1
  • Aspirin 1
  • Combination therapy: aspirin + acetaminophen + caffeine (NNT of 9 for pain freedom at 2 hours) 1, 2
• Take medication early when pain is still mild to maximize efficacy 1

Moderate to Severe Migraines

• Triptans are first-line therapy for moderate to severe attacks 1, 2
• Oral triptan options with good evidence:
  • Sumatriptan 50-100mg (doses of 50mg and 100mg provide greater effect than 25mg, but 100mg may not provide greater effect than 50mg) 3
  • Rizatriptan 1
  • Naratriptan 1
  • Zolmitriptan 1
• For fastest relief: Subcutaneous sumatriptan 6mg provides 70-82% pain relief within 15 minutes and 59% complete pain relief by 2 hours—the highest efficacy among all routes 1, 2
• If headache persists after 2 hours, a second dose may be given at least 2 hours after the first dose (maximum 200mg/24 hours for oral sumatriptan) 3

Migraines with Significant Nausea/Vomiting

• Use non-oral routes when significant nausea or vomiting is present 1
• Options include:
  • Intranasal sumatriptan 5-20mg 1
  • Subcutaneous sumatriptan 6mg 1, 2
  • Rectal suppositories 1

Adjunctive Antiemetic Therapy

Add an antiemetic 20-30 minutes before or with other medications to provide synergistic analgesia and improve outcomes 1

• Metoclopramide 10mg (oral or IV) treats both nausea and provides direct migraine analgesia through dopamine receptor antagonism 1, 2
• Prochlorperazine 10mg IV or 25mg orally/suppository (comparable efficacy to metoclopramide) 1, 2
• Do not restrict antiemetics only to vomiting patients—nausea itself is one of the most disabling migraine symptoms and warrants treatment 1, 2

Emergency Department/Urgent Care Protocol

For patients presenting with acute severe migraine requiring IV treatment:

• First-line "migraine cocktail": Ketorolac 30-60mg IV/IM + Metoclopramide 10mg IV 1, 2
• This combination provides rapid pain relief while minimizing side effects and rebound headache risk 2
• Dose adjustments: Reduce ketorolac for patients ≥65 years or with renal impairment 2
• For refractory cases: Add IV dihydroergotamine (DHE) 0.5-1.0mg or subcutaneous sumatriptan 6mg 2, 4

Second-Line Options

• Intranasal dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy 1
• IV DHE for severe or refractory migraines 2, 4

Critical Contraindications

Triptans and ergot derivatives are contraindicated in:

• Ischemic heart disease or previous myocardial infarction 1, 2
• Uncontrolled hypertension 1, 2
• Significant cardiovascular disease 1, 2
• Basilar or hemiplegic migraine 4

Ketorolac contraindications:

• Renal impairment (CrCl <30 mL/min) 1, 2
• Active GI bleeding 1, 2
• Aspirin/NSAID-induced asthma 1, 2

Metoclopramide contraindications:

• Pheochromocytoma 1, 2
• Seizure disorder 1, 2
• GI bleeding or obstruction 1, 2

Medications to Avoid

Opioids (hydromorphone, oxycodone) should NOT be used for migraine treatment due to questionable efficacy, high risk of dependency, and medication-overuse headache 1, 2, 4

• Reserve opioids only for cases where other medications cannot be used, when sedation is not a concern, and when abuse risk has been addressed 1

Prevention of Medication-Overuse Headache

Limit acute treatment to no more than twice weekly to prevent medication-overuse headache, which develops from frequent use (more than twice weekly) and leads to increasing headache frequency and potentially daily headaches 1, 2, 4

• Patients requiring acute treatment more than 2 days per week should be transitioned to preventive therapy 2, 5

Common Pitfalls to Avoid

• Do not delay treatment—begin as early as possible during the attack to improve efficacy 1
• Do not use triptans during aura phase—reserve for the headache phase 2
• Do not allow patients to increase frequency of acute medication use in response to treatment failure—this creates a vicious cycle of medication-overuse headache 1
• Screen for cardiovascular contraindications before administering triptans or ergotamines 2