Migraine Management
Acute Treatment Algorithm
For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 650-1000 mg), and for moderate to severe attacks, use triptans taken early while pain is still mild, with the combination of triptan plus NSAID providing superior efficacy to either agent alone. 1
First-Line Acute Treatment by Severity
Mild to Moderate Attacks:
- NSAIDs are first-line: ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 650-1000 mg 1
- Combination analgesics containing acetaminophen, aspirin, and caffeine are also effective 2, 3
Moderate to Severe Attacks:
- Triptans are first-line and must be taken early while pain is still mild for optimal effectiveness 1
- Oral triptans with strong evidence: sumatriptan, rizatriptan, naratriptan, zolmitriptan, almotriptan, and eletriptan 1
- Combination therapy (triptan + NSAID) is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 3
When Nausea/Vomiting is Present:
- Use non-oral formulations: subcutaneous sumatriptan 6 mg (most effective, 59% pain-free at 2 hours) or intranasal sumatriptan 5-20 mg 1, 3
- Add antiemetics: metoclopramide 10 mg or prochlorperazine 10 mg, which provide synergistic analgesia beyond antiemetic effects 2, 3
Third-Line Options
- For patients who fail triptan therapy or have cardiovascular contraindications, consider ditans (lasmiditan) or gepants (CGRP receptor antagonists) 2, 4
- Intranasal dihydroergotamine has good evidence for efficacy 3
Critical Frequency Limitation
Limit all acute medications to no more than 2 days per week to prevent medication overuse headache, which can paradoxically increase headache frequency and lead to daily headaches 1, 2, 3. If using acute medications more frequently, initiate preventive therapy immediately 1.
Medications to Avoid
- Opioids and barbiturates should be avoided due to risk of medication overuse headache, dependency, and limited evidence supporting their use 2, 3
Preventive Treatment
Initiate preventive therapy when patients experience frequent debilitating headaches despite adequate acute treatment, or when acute medications are used more than 2 days per week. 1
Specific Indications for Prevention
- Severe debilitating headaches despite adequate acute treatment 1
- Contraindications to acute treatment 1
- Acute medication use exceeding twice weekly 1
- Two or more attacks per month producing disability lasting 3 or more days 3
First-Line Preventive Medications
Oral Options (prioritize based on cost given similar net benefits):
- Beta-blockers: propranolol 80-240 mg/day or metoprolol 1, 5
- Tricyclic antidepressants: amitriptyline 30-150 mg/day (particularly useful for mixed migraine and tension-type headache) 1, 5
- Anticonvulsants: topiramate or valproic acid 1, 5
For Chronic Migraine (≥15 headache days per month):
- OnabotulinumtoxinA is first-line due to strong evidence 2, 5
- CGRP monoclonal antibodies (erenumab, others) for patients who have failed other preventive medications 2, 5, 4
Efficacy Timeline Expectations
- Oral preventive agents: assess efficacy after 2-3 months 3
- CGRP monoclonal antibodies: assess after 3-6 months 3
- OnabotulinumtoxinA: assess after 6-9 months 3
Special Population Considerations
Pediatric and Adolescent Patients:
- Acute treatment: ibuprofen is first-line 1
- Prevention: amitriptyline combined with cognitive behavioral therapy, topiramate, and propranolol have evidence 1
Patients of Childbearing Potential:
- Avoid topiramate and valproate unless effective contraception is ensured due to teratogenic risk 1, 2, 3
- Discuss adverse effects of all pharmacologic treatments during pregnancy and lactation before initiating therapy 1
Non-Pharmacological Management
Before initiating pharmacologic prevention, explore modifiable triggers and contributing factors, emphasizing hydration, regular adequate sleep, and regular physical activity. 1
Lifestyle Modifications
- Identify and manage migraine triggers: environmental factors, sleep pattern changes, diet, stress, hormonal changes 1, 6, 7
- Maintain regular sleep, eating, and work habits 8, 7
- Weight control and management of obesity 2, 7
- Regular physical activity 1, 7
Behavioral Interventions
- Cognitive behavioral therapy, relaxation training, and mindfulness decrease migraine frequency and should be combined with pharmacologic treatment 1, 5
- Biofeedback is a first-line preventive option with favorable evidence 5, 6
Nutraceuticals with Evidence
Additional Modalities
- Neuromodulation techniques have been approved for acute and/or preventive migraine treatment 2, 4
- Acupuncture can be helpful as an adjunct 6
Common Pitfalls to Avoid
Medication Overuse Headache:
- The most critical pitfall is allowing patients to increase frequency of acute medication use in response to treatment failure, creating a vicious cycle 3
- NSAIDs and triptans trigger medication overuse headache at ≥15 days/month and ≥10 days/month, respectively 3
- Transition to preventive therapy immediately while optimizing acute treatment strategy 1, 3
Triptan Failure:
- Failure of one triptan does not predict failure of others—try a different triptan before escalating 3
- Ensure early administration while pain is still mild for maximum effectiveness 2, 3
- Consider route change (e.g., subcutaneous sumatriptan) if oral formulations fail 3
Cardiovascular Considerations:
- Triptans are contraindicated in patients with ischemic vascular disease, vasospastic coronary disease, uncontrolled hypertension, or significant cardiovascular disease 3, 9
- Triptan-naive patients with multiple cardiovascular risk factors should have cardiovascular evaluation prior to receiving triptans 9
Comorbidity Management: