What are the treatment options for migraine?

Migraine Treatment Options

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

Acute Treatment Algorithm

First-Line Therapy

• For mild-to-moderate migraine: Use NSAIDs as initial therapy, with aspirin-acetaminophen-caffeine combination providing the strongest evidence (NNT 4 for pain relief at 2 hours). 1
• Specific NSAID options with proven efficacy: Ibuprofen 400-800 mg, naproxen sodium 500-825 mg, aspirin 1000 mg, or diclofenac potassium. 3, 1, 4
• Add an antiemetic (metoclopramide 10 mg or prochlorperazine 25 mg) 20-30 minutes before the NSAID if nausea is present, as this provides synergistic analgesia beyond just treating nausea. 1, 2

Second-Line Therapy: Triptans

• Escalate to triptans after NSAIDs fail in 2-3 consecutive attacks, or use immediately for moderate-to-severe attacks from onset. 3, 1
• Optimal triptan dosing: Sumatriptan 50-100 mg, rizatriptan 10 mg, or naratriptan 2.5 mg, taken early when pain is still mild for maximum effectiveness. 1, 5
• Combination therapy is superior: Triptan plus NSAID (e.g., sumatriptan 100 mg + naproxen 500 mg) provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone. 1, 2
• If one triptan fails: Try a different triptan, as failure of one does not predict failure of others. 3, 1

Route Selection Based on Symptoms

• Oral route: Standard for most patients without significant nausea/vomiting. 1, 4
• Subcutaneous sumatriptan 6 mg: Most effective route with 59% achieving pain-free response at 2 hours (NNT 2.3), providing relief within 15 minutes—use for rapid progression to peak intensity or severe vomiting. 2, 5, 6
• Intranasal route: Sumatriptan 20 mg or zolmitriptan when oral route compromised by nausea. 2, 6

Third-Line Therapy: Advanced Options

• For patients who fail all triptans or have contraindications (ischemic heart disease, uncontrolled hypertension, previous MI): Use CGRP antagonists (gepants) like rimegepant or ubrogepant (NNT 13 for pain freedom), lasmiditan (ditan), or dihydroergotamine (DHE). 1, 2, 5

Critical Medication Frequency Limits

• Strictly limit all acute medications to ≤2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 3, 1, 2
• NSAIDs: Maximum 15 days/month. 1
• Triptans: Maximum 10 days/month. 1, 5
• If exceeding these limits: Immediately initiate preventive therapy rather than increasing acute medication frequency. 1, 2

Medications to Avoid

• Never use opioids or butalbital-containing analgesics as they lead to dependency, medication-overuse headache, and loss of efficacy. 1, 2
• Paracetamol (acetaminophen) alone has inferior efficacy and should only be used when NSAIDs are contraindicated. 1

Preventive Treatment Indications

Initiate preventive therapy when: 3, 1, 4

• ≥2 attacks per month producing disability lasting ≥3 days
• Using acute medications >2 days per week
• Contraindication to or failure of acute treatments
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura)

First-Line Preventive Medications

• Beta-blockers without intrinsic sympathomimetic activity: Propranolol 80-240 mg/day, metoprolol, atenolol, or bisoprolol. 3, 4
• Topiramate: Effective but requires discussion of teratogenic effects with patients of childbearing potential. 3, 1
• Candesartan: ARB with proven efficacy. 3

Second-Line Preventive Medications

• Flunarizine, amitriptyline 30-150 mg/day (particularly useful for mixed migraine and tension-type headache). 3, 4
• Sodium valproate: Strictly contraindicated in women of childbearing potential due to teratogenic risk. 3

Third-Line Preventive Medications

• CGRP monoclonal antibodies: Erenumab, fremanezumab, galcanezumab, or eptinezumab—reserved for patients who have failed or cannot tolerate first- and second-line options. 3
• OnabotulinumtoxinA 155 units: FDA-approved specifically for chronic migraine (≥15 headache days/month). 1

Non-Pharmacological Therapies

• Evidence-supported options: Cognitive-behavioral therapy, biofeedback, relaxation training, and neuromodulatory devices—offer to all patients as part of comprehensive management. 3, 1
• Regular aerobic exercise: 40 minutes three times weekly is as effective as some preventive medications. 1
• Acupuncture: May provide benefit, though not superior to sham acupuncture in controlled trials. 3
• No evidence for: Physical therapy, spinal manipulation, or dietary approaches. 3

Lifestyle Modifications

• Maintain regular patterns: Consistent meal times, adequate hydration (avoid dehydration), and sufficient sleep with regular sleep-wake schedule. 1, 4
• Stress management: Relaxation techniques or mindfulness practices. 1, 4
• Identify triggers: Use headache diary to track severity, frequency, duration, treatment response, and potential triggers. 1, 4

Common Pitfalls to Avoid

• Treating too late: Triptans are most effective when taken early while pain is still mild, not after pain becomes severe. 1, 5
• Underdosing: Sumatriptan 100 mg is significantly more effective than 50 mg or 25 mg for pain-free response at 2 hours. 5, 7
• Not trying different triptans: Failure of one triptan does not predict failure of others—trial at least 2-3 different triptans before declaring triptan failure. 3, 1
• Allowing medication overuse: Monitor frequency closely and transition to preventive therapy before medication-overuse headache develops. 1, 2, 5