What is the recommended treatment for a migraine episode?

Treatment of Migraine Episode

For moderate to severe migraine, start combination therapy with a triptan (sumatriptan 50-100 mg) plus an NSAID (naproxen 500-825 mg or ibuprofen 400-800 mg) as first-line treatment, taken as early as possible when headache begins. 1

Initial Treatment Algorithm

Mild Migraine

• Start with an NSAID alone (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) or acetaminophen 1000 mg 1
• Alternative: combination of aspirin 250 mg + acetaminophen 250 mg + caffeine 65 mg 1
• Take medication immediately at headache onset while pain is still mild 1, 2

Moderate to Severe Migraine

• Use combination therapy from the start: triptan + NSAID (or acetaminophen if NSAIDs contraindicated) 1, 2
• Specific combinations with strongest evidence:
  • Sumatriptan 50-100 mg + naproxen 500 mg 1, 3
  • Any triptan + ibuprofen 400-800 mg 1
• This combination provides 130 additional patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 3

Dosing Specifics for Triptans

• Sumatriptan oral: 50-100 mg at onset; may repeat once after 2 hours if needed (maximum 200 mg/24 hours) 4
• The 100 mg dose does not provide greater efficacy than 50 mg but may have more adverse effects 4
• For rapid onset or severe nausea/vomiting: subcutaneous sumatriptan 6 mg provides relief within 15 minutes with 59% pain-free at 2 hours 1, 3

Escalation for Treatment Failure

If First-Line Therapy Fails After 2-3 Attacks

• Try a different triptan within the class—failure of one does not predict failure of others 1, 3
• Options include: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, zolmitriptan 1
• Consider route change (intranasal or subcutaneous) if oral formulations ineffective 1, 3

Second-Line Options for Triptan Failures

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 1, 2
• Ergot alkaloid: dihydroergotamine (intranasal or IV) 1, 3
• These should be reserved for patients who do not tolerate or have inadequate response to triptan + NSAID combination 1

Third-Line Option

• Lasmiditan (ditan class) for patients who have failed all other treatments in this guideline 1

Management of Associated Symptoms

Nausea and Vomiting

• Add antiemetic 20-30 minutes before analgesic: metoclopramide 10 mg or prochlorperazine 10-25 mg 1, 3
• These provide synergistic analgesia beyond antiemetic effects through central dopamine receptor antagonism 3
• For severe vomiting: use non-oral triptan (subcutaneous, intranasal) plus antiemetic 1

Critical Medication Frequency Limits

Limit ALL acute migraine medications to no more than 2 days per week (not 2 attacks per week, but 2 calendar days) 1, 2, 3

• NSAIDs/acetaminophen: medication overuse headache develops at ≥15 days/month 1
• Triptans: medication overuse headache develops at ≥10 days/month 1
• If using acute treatment more frequently, immediately initiate preventive therapy 1, 3

Medications to Avoid

Do not use opioids or butalbital-containing compounds for migraine treatment 1

• These lead to medication overuse headache, dependency, and loss of efficacy 1, 3
• They do not address migraine-specific pathophysiology 5

Special Populations

Pregnancy and Breastfeeding

• Discuss adverse effects of all pharmacologic treatments before prescribing 1
• Acetaminophen is generally preferred during pregnancy 1
• Avoid triptans, NSAIDs (especially third trimester), and ergot alkaloids unless benefits clearly outweigh risks 1

Cardiovascular Disease

• Triptans are contraindicated in ischemic heart disease, previous MI, uncontrolled hypertension, or significant cardiovascular disease 3, 6
• Use NSAIDs with caution in cardiovascular disease 1
• Consider gepants (CGRP antagonists) as they lack vasoconstrictive effects 1

Hepatic Impairment

• Maximum single dose of sumatriptan should not exceed 50 mg in mild to moderate hepatic impairment 4

Common Pitfalls to Avoid

• Taking medication too late in the attack: Efficacy decreases significantly if treatment is delayed until pain is severe 1, 2, 6
• Underdosing: Ensure adequate doses (ibuprofen 400-800 mg, not 200 mg; naproxen 500-825 mg; sumatriptan 50-100 mg, not 25 mg) 1, 4
• Using monotherapy for moderate-severe attacks: Combination therapy is superior to either agent alone 1, 2, 3
• Not recognizing medication overuse headache: If headaches increase in frequency despite treatment, suspect MOH and transition to preventive therapy 1, 3
• Trying only one triptan before declaring failure: Different triptans have different pharmacokinetics; trial at least 2-3 before escalating 1, 3

When to Initiate Preventive Therapy

Consider preventive medications if: 1, 3

• Two or more attacks per month causing disability for ≥3 days
• Using acute medications more than 2 days per week
• Inadequate response to optimized acute treatment
• Contraindications to acute treatments

Lifestyle Modifications (Adjunctive)

• Maintain hydration and regular meals 1, 2
• Ensure consistent sleep schedule (7-9 hours) 1, 2
• Regular moderate-to-intense aerobic exercise 1, 2
• Stress management with relaxation techniques or mindfulness 1, 2
• Weight loss if overweight or obese 1, 2
• Identify and avoid individual migraine triggers 1, 2