What are the treatment options for migraine?

Migraine Treatment

Acute Treatment Strategy

For acute migraine, use a stepped approach: start with NSAIDs (aspirin, ibuprofen, or naproxen) for mild-to-moderate attacks, and escalate to triptans for moderate-to-severe attacks or when NSAIDs fail. 1

First-Line Treatment for Mild-to-Moderate Attacks

• Aspirin-acetaminophen-caffeine combination is the strongest first-line recommendation, with a number needed to treat (NNT) of 4 for pain relief at 2 hours 1
• Alternative NSAIDs with proven efficacy include:
  • Aspirin 500-1000 mg 1
  • Ibuprofen 400-800 mg 2
  • Naproxen sodium 500-825 mg (can repeat every 2-6 hours, maximum 1.5 g/day) 2
  • Diclofenac potassium 1
• Paracetamol (acetaminophen) alone has less efficacy and should only be used if NSAIDs are not tolerated 1

Triptan Therapy for Moderate-to-Severe Attacks

Triptans should be offered when over-the-counter analgesics provide inadequate relief or for moderate-to-severe attacks from the outset. 1

Oral Triptan Dosing and Efficacy

• Sumatriptan 50-100 mg is the most studied triptan:
  • 100 mg dose: 62% achieve headache response (moderate/severe to mild/no pain) at 2 hours, with NNT of 4.7 for pain-free response 3, 4
  • 50 mg dose: 54-61% achieve headache response at 2 hours 3
  • 25 mg dose: 52% achieve headache response at 2 hours 3
• Other effective oral triptans include naratriptan, rizatriptan, and zolmitriptan 2

Critical Timing Principle

Administer triptans early in the attack while headache is still mild for maximum effectiveness. 1, 5 Treating during mild pain phase gives significantly better outcomes than waiting until pain is moderate or severe 4

Combination Therapy

Combining a triptan with an NSAID improves efficacy beyond either agent alone. 1, 5 Patients should begin treatment as soon as possible after migraine onset using combination therapy 1

Non-Oral Routes for Severe Attacks or Vomiting

• Subcutaneous sumatriptan 6 mg provides the most rapid and effective relief:
  • 59% pain-free at 2 hours (NNT 2.3) 6
  • Onset of action within 10-15 minutes 2, 7
  • Highest efficacy but also highest adverse event rate 6
• Intranasal sumatriptan 20 mg: NNT 3.5 for headache relief at 2 hours, useful when oral route not feasible 2, 6
• Intranasal zolmitriptan: Alternative intranasal option 2

Advanced Options When Triptans Fail or Are Contraindicated

If one triptan is ineffective, try others before abandoning the class entirely, as failure of one does not predict failure of others. 1

For patients who fail all triptans or have contraindications (coronary artery disease, uncontrolled hypertension, stroke history), consider: 1, 3

• CGRP antagonists (gepants): Rimegepant or ubrogepant (NNT 13 for pain freedom) or zavegepant 1
• Lasmiditan (ditan): Robust benefit but significant adverse effects including driving restrictions (NNT for harm = 4) 1
• Dihydroergotamine (DHE): Intranasal or IV formulation 1, 2

Managing Associated Symptoms

• Antiemetics provide dual benefit: Metoclopramide 10 mg IV or prochlorperazine 10 mg IV treat nausea and provide synergistic analgesia for migraine pain 2
• Use non-oral routes when significant nausea or vomiting is present 1, 2

IV Treatment for Severe Attacks in Emergency Settings

The most effective IV combination is metoclopramide 10 mg IV plus ketorolac 30 mg IV, providing rapid pain relief while minimizing rebound headache risk 2

Critical Medication Overuse Prevention

Limit acute medication use to prevent medication overuse headache: ≤15 days/month for NSAIDs, ≤10 days/month for triptans, and no more than twice weekly overall. 1, 2 Exceeding these limits can paradoxically increase headache frequency and lead to daily headaches 2

Medications to Avoid

Avoid opioids and butalbital-containing analgesics for migraine treatment as they lead to dependency, rebound headaches, and eventual loss of efficacy 1, 2

Preventive Treatment Indications

Consider preventive therapy when patients have: 1, 5

• 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 Options

• Beta-blockers (propranolol 80-240 mg/day or timolol 20-30 mg/day) 2, 5
• Topiramate (requires discussion of teratogenic effects with patients of childbearing potential) 1, 5
• ACE inhibitors or ARBs (candesartan) 1, 5
• OnabotulinumtoxinA 155 units specifically for chronic migraine (≥15 headache days per month) 1

Non-Pharmacologic Interventions

Lifestyle modifications are essential and should be addressed in all patients: 1, 5

• Maintain regular meals and adequate hydration 1, 5
• Ensure consistent sleep schedule with sufficient sleep 1, 5
• Regular moderate-to-intense aerobic exercise (40 minutes three times weekly) is as effective as some preventive medications 1
• Manage stress with relaxation techniques or mindfulness practices 1, 5

Behavioral therapies with proven efficacy include: 1

• Cognitive-behavioral therapy
• Biofeedback
• Relaxation training

Monitoring and Follow-Up

Have patients maintain a headache diary tracking severity, frequency, duration, disability, treatment response, and adverse effects to determine treatment efficacy, identify analgesic overuse, and monitor for medication overuse headache 1, 5