What are the treatment options for migraines?

Migraine Treatment

For acute migraine treatment, start with NSAIDs or aspirin-acetaminophen-caffeine combination for mild-to-moderate attacks, escalate to triptans for moderate-to-severe attacks or when first-line therapy fails, and reserve newer agents (gepants, lasmiditan, DHE) for triptan failures or contraindications. 1

Acute Treatment Algorithm

Mild-to-Moderate Attacks (First-Line)

• Aspirin-acetaminophen-caffeine combination is the strongest first-line recommendation, with a number needed to treat (NNT) of 9 for pain freedom at 2 hours and 4 for pain relief at 2 hours 1
• Alternative NSAIDs with proven efficacy include ibuprofen, naproxen sodium (500-825 mg initially), diclofenac potassium, and aspirin alone 1, 2
• Acetaminophen 1000 mg can be used as monotherapy but has less efficacy than NSAIDs or combination therapy and should be reserved for patients intolerant of NSAIDs 1, 3
• Take medication as early as possible when headache is still mild to maximize efficacy 1, 2

Moderate-to-Severe Attacks (Triptan Strategy)

• Offer triptans to patients for whom over-the-counter analgesics provide inadequate relief 1
• Oral triptans with good evidence include sumatriptan (25-100 mg), rizatriptan, naratriptan, and zolmitriptan 2
• Combining a triptan with an NSAID or acetaminophen improves efficacy over either agent alone 1
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% pain-free at 2 hours) and fastest onset (15 minutes), making it ideal for rapidly escalating attacks or when vomiting prevents oral administration 2, 4
• Intranasal sumatriptan (5-20 mg) is useful when significant nausea or vomiting is present 2
• If one triptan is ineffective after 2-3 attacks, try a different triptan as failure of one does not predict failure of others 1, 2

Managing Nausea and Vomiting

• Add metoclopramide 10 mg or prochlorperazine 10 mg (oral or IV) 20-30 minutes before analgesics to provide synergistic analgesia and improve gastric motility 1, 2
• Antiemetics provide direct analgesic effects through central dopamine receptor antagonism, not just symptom relief 2
• Use non-oral routes (intranasal, subcutaneous, IV, rectal) when significant nausea or vomiting is present early in the attack 1, 2

Refractory Attacks (Third-Line)

• For patients who fail all available triptans or have contraindications (coronary artery disease, uncontrolled hypertension, stroke history), options include: 1, 4
  • CGRP antagonists (gepants): rimegepant or ubrogepant (NNT of 13 for pain freedom at 2 hours) 1
  • Zavegepant (intranasal gepant) 1
  • Dihydroergotamine (DHE) intranasal or IV 1, 2
  • Lasmiditan (ditan) - has robust efficacy but significant adverse effects including driving restrictions (NNT for harm of 4) 1

Emergency/Urgent Care Treatment

• IV ketorolac 30 mg plus IV metoclopramide 10 mg is first-line combination therapy for severe migraine requiring parenteral treatment 2, 3
• Prochlorperazine 10 mg IV is equally effective to metoclopramide with a more favorable side effect profile (21% vs 50% adverse events) 2
• IV dihydroergotamine (DHE) is an alternative for patients with contraindications to NSAIDs 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, 3
• Initiate preventive therapy if acute treatment is needed more than 2 days per week 1, 3
• Avoid opioids and butalbital-containing analgesics as they lead to dependency, rebound headaches, and loss of efficacy 1, 2

Preventive Therapy Indications

Consider preventive therapy for patients with: 1

• 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
• Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura)

First-Line Preventive Medications

• Propranolol 80-240 mg/day or timolol 20-30 mg/day (beta-blockers with consistent efficacy evidence) 2
• Topiramate (effective but requires discussion of teratogenic effects with patients of childbearing potential) 1
• Amitriptyline 30-150 mg/day (particularly for mixed migraine and tension-type headache) 2
• Divalproex sodium/sodium valproate (caution: weight gain, hair loss, tremor, teratogenic potential) 2
• ACE inhibitors or ARBs if first-line agents are not tolerated 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 medication overuse headache before establishing chronic migraine diagnosis 1
• Limit as-needed medication use and monitor closely for medication overuse patterns 1

Non-Pharmacologic Treatments

• Cognitive-behavioral therapy, biofeedback, and relaxation training should be offered to all patients as part of comprehensive management 1
• Regular moderate-to-intense aerobic exercise (40 minutes three times weekly) is as effective as some preventive medications 1
• Maintain regular meals, adequate hydration, and consistent sleep schedules 1
• Manage stress with relaxation techniques or mindfulness practices 1
• Use a headache diary to identify triggers, monitor treatment efficacy, and detect analgesic overuse 1

Special Populations

• Pregnant or breastfeeding patients: acetaminophen is first-line, with NSAIDs usable prior to the third trimester 3
• Patients with cardiovascular disease: avoid triptans, ergots, and lasmiditan; use NSAIDs or gepants 4
• Patients with uncontrolled hypertension: avoid triptans and ergots 4

Common Pitfalls to Avoid

• Do not delay treatment - triptans are most effective when taken early while headache is still mild 1
• Do not abandon triptans after one failure - try different triptans or combination therapy before escalating 1
• Do not allow patients to increase acute medication frequency in response to treatment failure - this creates medication overuse headache; instead transition to preventive therapy 2
• Do not use opioids routinely - reserve only for when other medications cannot be used and abuse risk has been addressed 2
• Monitor total daily acetaminophen intake to ensure it does not exceed 4000 mg per day from all sources 2