What are the treatment options for migraines?

Migraine Treatment

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 escalate to a triptan combined with an NSAID for moderate-to-severe attacks or when NSAIDs alone fail—this combination therapy is superior to either agent alone and represents the strongest evidence-based approach. 1, 2

Acute Treatment Algorithm

Mild-to-Moderate Attacks

• First-line: NSAIDs with proven efficacy include ibuprofen (400-800 mg), naproxen sodium (500-825 mg), aspirin (1000 mg), or diclofenac potassium 1, 3
• Alternative: Combination analgesic containing acetaminophen/aspirin/caffeine (number needed to treat of 9 for pain freedom at 2 hours) 1, 2
• Acetaminophen 1000 mg has less efficacy than NSAIDs and should be reserved for patients intolerant of NSAIDs 1, 2
• Take medication as early as possible when headache is still mild to maximize effectiveness 1, 3

Moderate-to-Severe Attacks

• First-line: Triptan + NSAID combination therapy—this provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 3
• Specific triptan options with good evidence: sumatriptan 50-100 mg, rizatriptan 10 mg, naratriptan, zolmitriptan 1, 3, 4
• If one triptan is ineffective after 2-3 attacks, try a different triptan—failure of one does not predict failure of others 1, 3
• Subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours) for patients with rapid progression or severe vomiting 3, 4

Managing Nausea and Vomiting

• Add metoclopramide 10 mg or prochlorperazine 10 mg (oral, IV, or rectal) 20-30 minutes before analgesics—these provide synergistic analgesia beyond antiemetic effects 1, 3
• Use non-oral routes (intranasal, subcutaneous, IV, rectal) when significant nausea/vomiting is present 1, 3

Advanced Treatment Options (When Triptans Fail or Are Contraindicated)

• CGRP antagonists (gepants): Rimegepant or ubrogepant (number needed to treat of 13 for pain freedom) 1, 2
• Lasmiditan (ditan): Effective but has significant adverse effects including driving restrictions (number needed to harm of 4) 1
• Dihydroergotamine (DHE): Intranasal or IV formulations have good evidence for efficacy 1, 3

Emergency Department/Urgent Care Treatment

• IV combination therapy: Metoclopramide 10 mg IV + ketorolac 30 mg IV provides rapid relief with minimal rebound risk 3, 2
• Prochlorperazine 10 mg IV is comparable to metoclopramide in efficacy 3
• Avoid ketorolac in patients with renal impairment, GI bleeding history, or significant cardiovascular disease 3

Critical Medication Frequency Limits

Strictly 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, which paradoxically increases headache frequency and can lead to daily headaches. 1, 3, 2, 4, 5

Medications to Avoid

• Never use opioids or butalbital-containing analgesics as first-line therapy—they lead to dependency, medication overuse headache, and loss of efficacy 1, 3, 2
• Opioids should only be reserved for cases where all other medications cannot be used, sedation is not a concern, and abuse risk has been addressed 3

When to Initiate Preventive Therapy

Consider preventive therapy if: 1, 2

• Two or more attacks per month producing disability lasting 3+ days
• Using acute medications more than twice per week
• Contraindication to or failure of acute treatments
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura)

Preventive Medication Options

• First-line: Propranolol 80-240 mg/day, topiramate (discuss teratogenic effects with women of childbearing potential), or ACE inhibitors/ARBs 1
• Chronic migraine (≥15 headache days/month): OnabotulinumtoxinA 155 units is FDA-approved and effective based on large-scale trials 1
• CGRP monoclonal antibodies: Consider when oral preventives fail, assess efficacy after 3-6 months 3

Non-Pharmacologic Interventions

• 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 have good evidence for efficacy 1
• Maintain regular meals, adequate hydration, sufficient sleep, and stress management with mindfulness practices 1, 2
• Use a headache diary to identify triggers, monitor treatment efficacy, and track medication use 1

Special Populations

Pregnancy and Lactation

• First-line: Acetaminophen 1000 mg 2
• NSAIDs can be used prior to third trimester 3, 2
• Avoid triptans, ergotamines, and valproate (strictly contraindicated due to teratogenic risk) 3

Pediatric Patients (6-17 years)

• Weight-based dosing: Rizatriptan 5 mg for patients 20-40 kg, 10 mg for ≥40 kg 4
• Acetaminophen, ibuprofen, and intranasal sumatriptan are effective 3

Contraindications to Triptans

Triptans are contraindicated in: 4, 5

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

Common Pitfalls to Avoid

• Taking medication too late: Triptans are most effective when taken early while headache is still mild 1, 3
• Underdosing: Use adequate doses (e.g., sumatriptan 100 mg, not 25-50 mg) for moderate-to-severe attacks 3
• Not combining therapies: Triptan + NSAID is superior to monotherapy 1, 3
• Allowing medication overuse: Monitor frequency strictly and transition to preventive therapy when needed 1, 3, 2
• Using opioids routinely: This creates dependency and worsens long-term outcomes 1, 3, 2