What helps with migraine headaches?

Treatment of Migraine Headache

For mild to moderate migraine, start with an NSAID (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) or acetaminophen 1000 mg; for moderate to severe migraine, use combination therapy with a triptan (sumatriptan 50-100 mg) plus an NSAID, which provides superior efficacy compared to either agent alone. 1

First-Line Treatment Algorithm

Mild to Moderate Migraine

• NSAIDs are the first-line choice, with strong evidence supporting ibuprofen 400-800 mg, naproxen sodium 500-825 mg, aspirin 1000 mg, or diclofenac potassium 1, 2
• Ibuprofen 400 mg provides 2-hour headache relief in 57% of patients (versus 25% with placebo), with an NNT of 3.2 3
• Acetaminophen 1000 mg is an alternative, providing 2-hour headache relief in 56% of patients (versus 36% with placebo), with an NNT of 5.0 4
• The combination of acetaminophen 250 mg + aspirin 250 mg + caffeine 65 mg is effective and recommended 1, 5

Moderate to Severe Migraine

• Combination therapy with a triptan plus an NSAID is superior to either agent alone and represents the strongest recommendation from the 2025 American College of Physicians guidelines 1, 5
• Sumatriptan 50-100 mg plus naproxen sodium 500 mg provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 5
• Oral sumatriptan achieves 2-hour headache relief in 61-62% of patients (versus 27% with placebo) at doses of 50-100 mg 6
• Take medication as early as possible during the attack, ideally when pain is still mild, to maximize effectiveness 1, 2

Second-Line Options for Inadequate Response

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant for patients who do not tolerate or have inadequate response to triptan plus NSAID combination 1
• Ergot alkaloid: dihydroergotamine (DHE) nasal spray or injectable formulations 1, 5
• Ditan: lasmiditan for patients who do not tolerate or have inadequate response to all other treatments 1, 2

Special Considerations

Severe Nausea or Vomiting

• Use non-oral triptan formulations (subcutaneous sumatriptan 6 mg provides the highest efficacy with onset within 15 minutes) 5
• Add an antiemetic: metoclopramide 10 mg IV or prochlorperazine 10 mg IV provides direct analgesic effects beyond treating nausea 5

Intravenous Treatment for Severe Attacks

• First-line IV cocktail: metoclopramide 10 mg IV plus ketorolac 30 mg IV provides rapid pain relief with minimal rebound headache risk 5
• Alternative: dihydroergotamine IV 5

Critical Medication Frequency Limits

Limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which occurs with NSAIDs used ≥15 days/month or triptans used ≥10 days/month 1, 5, 2

If you need acute treatment more than twice weekly, initiate preventive therapy immediately (propranolol 80-240 mg/day, topiramate, or CGRP monoclonal antibodies) 5

Medications to Avoid

• Do not use opioids or butalbital for acute migraine treatment due to risk of dependency, medication-overuse headache, and eventual loss of efficacy 1, 5

Lifestyle Modifications

• Maintain adequate hydration, regular meals, sufficient and consistent sleep (7-9 hours), regular moderate-to-intense aerobic exercise, stress management with relaxation techniques or mindfulness, and weight loss if overweight or obese 1, 7

Cost Considerations

• Prescribe less costly recommended medications: generic NSAIDs and triptans are preferred over newer CGRP antagonists (annualized cost $4,959-$8,800) unless other treatments have failed 1