What are the treatment options for migraine?

Migraine Treatment

For acute migraine, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) for mild-to-moderate attacks, and escalate immediately to a triptan plus NSAID combination for moderate-to-severe attacks or when NSAIDs fail after 2-3 episodes. 1, 2

Acute Treatment Algorithm

Mild-to-Moderate Migraine (First-Line)

• Begin with over-the-counter NSAIDs or combination analgesics containing acetaminophen, aspirin, and caffeine (aspirin-acetaminophen-caffeine has NNT of 4 for pain relief at 2 hours). 1, 2
• Specific NSAIDs with proven efficacy include aspirin 1000 mg, ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or diclofenac potassium. 1, 3
• Acetaminophen 1000 mg has less efficacy than NSAIDs and should only be used when NSAIDs are contraindicated. 1, 2
• Take medication as early as possible when headache is still mild to maximize effectiveness. 1, 4

Moderate-to-Severe Migraine (First-Line)

• Combine a triptan with an NSAID (e.g., sumatriptan 50-100 mg plus naproxen sodium 500 mg) as this combination is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours. 1, 3
• Oral triptans with strong evidence include sumatriptan 50-100 mg, rizatriptan, naratriptan, and zolmitriptan. 3, 4
• Sumatriptan 50-100 mg achieves headache response in 50-62% of patients at 2 hours compared to 17-27% with placebo. 4
• If one triptan fails after adequate trial, try a different triptan as failure of one does not predict failure of others. 1, 3

Route Selection Based on Symptoms

• Use non-oral routes when significant nausea or vomiting is present early in the attack. 1, 3
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% complete pain relief at 2 hours, 70-82% pain relief within 15 minutes) but has higher adverse event rates. 3, 4
• Intranasal sumatriptan (5-20 mg) or zolmitriptan are alternatives for patients unable to take oral medications. 3

Managing Nausea and Vomiting

• Add metoclopramide 10 mg or prochlorperazine 10 mg (oral/IV) 20-30 minutes before analgesics to provide synergistic analgesia beyond antiemetic effects and improve gastric motility. 1, 3
• These antiemetics have independent analgesic benefit through central dopamine receptor antagonism. 3

Advanced Treatment Options (Second/Third-Line)

For Triptan Failures or Contraindications

• CGRP antagonists (gepants): rimegepant or ubrogepant (NNT of 13 for pain freedom at 2 hours). 1, 2
• Lasmiditan (ditan): demonstrates robust benefit for pain freedom but has significant adverse effects including driving restrictions (NNT for harm of 4). 1
• Dihydroergotamine (DHE): intranasal or IV formulation has good evidence for efficacy as monotherapy. 1, 3

Emergency Department/Urgent Care IV Treatment

• IV metoclopramide 10 mg plus IV ketorolac 30 mg as first-line combination therapy for severe migraine requiring parenteral treatment. 3, 2
• Ketorolac has rapid onset with approximately 6 hours duration and minimal rebound headache risk. 3
• Alternative: IV prochlorperazine 10 mg (comparable efficacy to metoclopramide with 21% adverse event rate vs 50% for chlorpromazine). 3

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. 1, 2, 4

• Medication overuse headache presents as daily headaches or marked increase in migraine frequency. 4
• If needing acute treatment more than twice weekly, initiate preventive therapy immediately. 1, 2

Preventive Therapy 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, prolonged aura)

First-Line Preventive Options

• Beta-blockers: propranolol 80-240 mg/day or timolol 20-30 mg/day. 1
• Topiramate: effective but requires discussion of teratogenic effects with patients of childbearing potential. 1
• Amitriptyline 30-150 mg/day: particularly for patients with mixed migraine and tension-type headache. 1
• OnabotulinumtoxinA 155 units: FDA-approved specifically for chronic migraine (≥15 headache days/month) based on large-scale placebo-controlled trials. 1

Non-Pharmacologic Treatments

• 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 should be offered to all patients as part of comprehensive management. 1
• Maintain regular meals, adequate hydration, and consistent sleep schedule. 1
• Use a headache diary to identify triggers, monitor treatment efficacy, and detect analgesic overuse. 1

Medications to Avoid

Never use opioids or butalbital-containing analgesics for migraine treatment as they lead to dependency, rebound headaches, and eventual loss of efficacy. 1, 3

Triptan Contraindications

Triptans are contraindicated in: 4

• Ischemic heart disease or coronary artery disease
• Wolff-Parkinson-White syndrome or cardiac accessory conduction pathway disorders
• Prinzmetal's variant angina
• History of stroke or transient ischemic attack
• Uncontrolled hypertension
• Hemiplegic migraine

Special Population Considerations

• Pregnant/breastfeeding patients: acetaminophen first-line; NSAIDs usable prior to third trimester. 2
• Cardiovascular disease: avoid triptans; consider CGRP antagonists, DHE (if no vascular contraindications), or NSAIDs. 3, 4