What are the treatment options for migraines?

Migraine Treatment

Acute Treatment Algorithm

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg) or the combination of aspirin-acetaminophen-caffeine; for moderate to severe attacks, use a triptan combined with an NSAID, taken as early as possible when pain is still mild. 1

First-Line Treatment for Mild to Moderate Attacks

• Begin with NSAIDs that have proven efficacy: ibuprofen, naproxen sodium, aspirin, or diclofenac potassium 1, 2
• The aspirin-acetaminophen-caffeine combination is strongly recommended as first-line therapy with a number needed to treat of 9 for pain freedom at 2 hours 1
• Acetaminophen alone has less efficacy and should only be used when NSAIDs are not tolerated 1
• Take medication immediately at migraine onset—early treatment significantly improves efficacy 1, 2

Escalation to Triptans for Moderate to Severe Attacks

• Offer triptans when over-the-counter analgesics provide inadequate relief or for attacks that are moderate to severe from onset 1, 2
• Combining a triptan with an NSAID provides superior efficacy compared to either agent alone—this is the strongest recommendation for moderate to severe migraine 1, 2
• Oral triptans with good evidence include sumatriptan 50-100 mg, rizatriptan, naratriptan, and zolmitriptan 1, 2
• Triptans work best when taken early while headache is still mild 1
• If one triptan fails, try a different triptan—failure of one does not predict failure of others 1, 2

Route Selection Based on Symptoms

• Use non-oral routes (subcutaneous, intranasal, or rectal) when significant nausea or vomiting is present 1, 2
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% pain-free at 2 hours) with the fastest onset (15 minutes), though with higher adverse event rates 2, 3
• Intranasal sumatriptan 5-20 mg is effective for patients with early vomiting 2

Managing Nausea and Vomiting

• Add antiemetics like metoclopramide 10 mg or prochlorperazine 10 mg (oral, IV, or rectal) to treat nausea and improve gastric motility, which enhances absorption of co-administered medications 1, 2
• Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism, not just antiemetic effects 2
• Prochlorperazine 10 mg IV effectively relieves headache pain and is comparable to metoclopramide in efficacy 2

Third-Line Options for Refractory Cases

• For patients who fail all triptans or have contraindications (ischemic heart disease, uncontrolled hypertension, cardiovascular disease), use CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 1, 2
• Lasmiditan (ditan) is an alternative but has significant adverse effects including driving restrictions 1
• Dihydroergotamine (DHE) intranasal or IV has good evidence for efficacy as monotherapy 1, 2

Critical Medication Overuse Prevention

Limit all acute migraine medications to no more than 2 days per week (≤10 days/month for triptans, ≤15 days/month for NSAIDs) to prevent medication overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 2

• If you need acute treatment more than twice weekly, initiate preventive therapy immediately 1, 2

Medications to Avoid

• Avoid opioids and butalbital-containing analgesics—they lead to dependency, rebound headaches, and eventual loss of efficacy 1, 2
• Reserve opioids only for cases where other medications cannot be used, sedation is not a concern, and abuse risk has been addressed 2

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Preventive Treatment Indications

Consider preventive therapy when: 1

• Two or more attacks per month producing disability lasting 3+ days
• 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 2
• Topiramate (discuss teratogenic effects with patients of childbearing potential) 1
• Amitriptyline 30-150 mg/day, particularly for mixed migraine and tension-type headache 2
• For chronic migraine (≥15 headache days/month): onabotulinumtoxinA 155 units is FDA-approved and effective 1

Alternative Preventive Options

• ACE inhibitors, ARBs, or SSRIs if first-line treatments are not tolerated 1
• Start preventive medications at low doses and gradually increase until desired outcomes are achieved 1
• Allow 2-3 months for oral agents, 3-6 months for CGRP monoclonal antibodies, and 6-9 months for onabotulinumtoxinA to assess efficacy 2

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Non-Pharmacologic Treatments

• Cognitive-behavioral therapy, biofeedback, and relaxation training should be offered to all patients—these have good evidence for efficacy and should be part of comprehensive management 1
• 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

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Lifestyle Modifications

• Maintain regular meals and stay well hydrated 1
• Ensure sufficient and consistent sleep 1, 4
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1
• Identify and reduce aggravating factors using a headache diary 1

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Emergency Department/Urgent Care IV Treatment

For severe migraine requiring IV treatment: 2

• Metoclopramide 10 mg IV plus ketorolac 30 mg IV provides rapid pain relief with minimal rebound headache risk 2
• Prochlorperazine 10 mg IV is an alternative to metoclopramide with comparable efficacy 2
• Dihydroergotamine (DHE) IV is an alternative for patients with contraindications to NSAIDs 2
• Avoid opioids in the emergency setting—they lead to medication overuse headache and dependency 2

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Common Pitfalls to Avoid

• 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. Instead, transition to preventive therapy while optimizing acute treatment strategy. 2
• Do not delay triptan administration—they are most effective when taken early while pain is mild 1
• Do not assume all triptans will fail if one fails—try different triptans before moving to third-line agents 1, 2
• Do not use acetaminophen alone as first-line therapy—it has inferior efficacy compared to NSAIDs 1
• Monitor total daily acetaminophen intake to ensure it does not exceed 4000 mg per day from all sources 2