What are the treatment options for migraine?

Migraine Treatment

For acute migraine, start with NSAIDs (aspirin, ibuprofen, or naproxen) for mild-to-moderate attacks, escalate to triptans for moderate-to-severe attacks or when NSAIDs fail, and consider preventive therapy if attacks occur more than twice weekly. 1

Acute Treatment Algorithm

First-Line: NSAIDs for Mild-to-Moderate Attacks

• Begin with over-the-counter NSAIDs including aspirin 500-1000 mg, ibuprofen 400-800 mg, or naproxen sodium 500-825 mg at migraine onset. 1, 2
• Diclofenac potassium is also effective with proven efficacy. 1
• The aspirin-acetaminophen-caffeine combination (e.g., Excedrin Migraine) is strongly recommended as first-line therapy with an NNT of 4 for pain relief at 2 hours. 1
• Paracetamol (acetaminophen) alone has less efficacy and should only be used in patients intolerant of NSAIDs. 1

Second-Line: Triptans for Moderate-to-Severe Attacks

• Offer triptans when over-the-counter analgesics provide inadequate relief or for moderate-to-severe attacks from the outset. 1, 3
• Administer triptans early in the attack while headache is still mild for maximum effectiveness. 1, 3
• Oral sumatriptan 50-100 mg is the most studied triptan, with the 100 mg dose achieving pain-free response in 59% at 2 hours (NNT 4.7) versus 50 mg achieving 50% pain-free response (NNT 6.1). 4, 5
• Other effective oral triptans include naratriptan, rizatriptan, and zolmitriptan. 2
• Combining a triptan with an NSAID improves efficacy beyond either agent alone. 1, 3
• If one triptan is ineffective after 2-3 adequate trials, try a different triptan as failure of one does not predict failure of others. 1

Route Selection Based on Symptoms

• For patients with significant nausea/vomiting, use non-oral routes: subcutaneous sumatriptan 6 mg (most effective, 59% pain-free at 2 hours, NNT 2.3), intranasal sumatriptan 20 mg (NNT 3.5), or intranasal zolmitriptan. 1, 2, 6
• Subcutaneous sumatriptan provides the most rapid pain relief (within 15 minutes) but has higher adverse event rates. 6

Adjunctive Antiemetic Therapy

• Add metoclopramide 10 mg IV/oral or prochlorperazine 10 mg IV/25 mg oral to treat nausea and improve gastric motility, which enhances absorption of co-administered medications. 1, 2
• Antiemetics provide synergistic analgesia beyond their antiemetic effects through central dopamine receptor antagonism. 2

Third-Line Options for Refractory Cases

• For patients who fail all available triptans or have contraindications (coronary artery disease, uncontrolled hypertension, stroke history), use CGRP antagonists (gepants) like rimegepant or ubrogepant (NNT 13), lasmiditan (ditan), or dihydroergotamine (DHE). 1, 4
• Lasmiditan demonstrates robust benefit but has significant adverse effects including driving restrictions (NNH 4). 1

Critical Medication Overuse Prevention

• Limit acute medication use to ≤10 days/month for triptans and ≤15 days/month for NSAIDs to prevent medication overuse headache. 1
• Avoid opioids and butalbital-containing analgesics entirely for migraine treatment as they lead to dependency, rebound headaches, and loss of efficacy. 1, 2

Preventive Therapy Indications

Consider preventive therapy when patients have: 1, 3

• 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, timolol 20-30 mg/day), topiramate (discuss teratogenic effects with childbearing patients), or candesartan. 1, 3
• OnabotulinumtoxinA 155 units is FDA-approved specifically for chronic migraine (≥15 headache days/month). 1
• ACE inhibitors, ARBs, or SSRIs can be considered if first-line agents are not tolerated. 1

Non-Pharmacologic Preventive Measures

• Regular moderate-to-intense aerobic exercise 40 minutes three times weekly is as effective as some preventive medications. 1
• Cognitive-behavioral therapy, biofeedback, and relaxation training have good evidence for efficacy and should be offered to all patients. 1
• Maintain regular meals, adequate hydration, consistent sleep schedule, and stress management with relaxation techniques or mindfulness practices. 1, 3

Monitoring and Follow-Up

• Have patients maintain a headache diary tracking severity, frequency, duration, disability, treatment response, and adverse effects to determine treatment efficacy and identify analgesic overuse. 1, 3
• Start preventive medications at low doses and gradually increase until desired outcomes are achieved. 1
• Switch preventive treatment if adequate response is not achieved during a reasonable trial period (2-3 months for oral agents, 3-6 months for CGRP monoclonal antibodies, 6-9 months for onabotulinumtoxinA). 2

Common Pitfalls to Avoid

• Do not delay triptan administration until pain is severe—early treatment during mild pain phase provides significantly better outcomes. 1, 5
• Do not allow patients to increase frequency of acute medication use in response to treatment failure—this creates medication overuse headache; instead transition to preventive therapy. 2
• Sumatriptan is contraindicated in patients with coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, stroke/TIA history, or Wolff-Parkinson-White syndrome. 4