Effective Medications for Migraine Headaches
For mild to moderate migraines, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-550 mg, or aspirin 1000 mg), and for moderate to severe migraines, use the triple combination of sumatriptan 50-100 mg + naproxen 500-550 mg + metoclopramide 10 mg. 1
Treatment Algorithm Based on Migraine Severity
Mild to Moderate Migraines (First-Line)
NSAIDs are the recommended first-line treatment, with ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg providing pain relief in approximately 50-57% of patients within 2 hours 2, 3, 4
Combination therapy with acetaminophen 1000 mg + aspirin 1000 mg + caffeine 130 mg is an effective alternative when single NSAIDs provide inadequate relief 2
Take medication as early as possible during the attack while pain is still mild, as this significantly improves efficacy 2, 5
Moderate to Severe Migraines (First-Line)
The standard "headache cocktail" consists of sumatriptan 50-100 mg + naproxen 500-550 mg + metoclopramide 10 mg, all taken together at migraine onset 1
This triple combination provides superior efficacy compared to any single agent, with sumatriptan achieving 52-62% pain-free rates at 2 hours and 65-79% at 4 hours 6
Metoclopramide serves dual purposes: treating nausea and providing direct analgesic effects through dopamine receptor antagonism, not just as an antiemetic 2, 1
Alternative Oral Triptans
If sumatriptan is ineffective or not tolerated, try a different triptan (rizatriptan, zolmitriptan, or naratriptan), as failure of one does not predict failure of others 2
Standard sumatriptan dosing is 50-100 mg orally, with maximum daily dose of 200 mg per 24 hours 1, 6
Emergency/Severe Presentations (IV Treatment)
For patients requiring IV therapy, use ketorolac 30-60 mg IV + metoclopramide 10 mg IV as the first-line combination 2, 1
Prochlorperazine 10 mg IV is equally effective as metoclopramide and can be substituted 2
Subcutaneous sumatriptan 6 mg provides the fastest and most effective relief, achieving pain relief in 70-82% within 15 minutes, but has higher adverse event rates 2, 6
Critical Frequency Limitation to Prevent Medication-Overuse Headache
Limit all acute migraine medications to no more than 2 days per week (not 2 doses, but 2 separate days), as exceeding this frequency leads to medication-overuse headache and paradoxically increases headache frequency 2, 1, 5
If you need acute treatment more than twice weekly, initiate preventive therapy with propranolol 80-240 mg/day, topiramate, or amitriptyline 30-150 mg/day 2, 5
Important Contraindications and Cautions
Sumatriptan is contraindicated in coronary artery disease, previous MI, Prinzmetal angina, or uncontrolled hypertension 1, 6
NSAIDs are contraindicated in aspirin/NSAID-induced asthma, severe renal impairment (CrCl <30 mL/min), or active GI bleeding 2, 1
Avoid opioids and butalbital-containing compounds as they cause dependency, medication-overuse headache, and have questionable efficacy for migraine 2, 1, 5
Common Pitfalls to Avoid
Do not use acetaminophen alone for migraine—it is ineffective as monotherapy and should only be used in combination formulations 1
Do not delay treatment—waiting until pain becomes severe significantly reduces medication efficacy 2, 5
Do not restrict metoclopramide only to patients who are vomiting—nausea itself is disabling and warrants treatment, plus metoclopramide provides direct migraine pain relief 2
Approximately 40% of patients experience headache recurrence within 24 hours; this can be managed by repeating the sumatriptan dose after 2 hours (oral) or 1 hour (subcutaneous) 1, 6