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, naproxen sodium, aspirin, or diclofenac potassium 1, 3
• Alternative: Combination analgesic containing acetaminophen/aspirin/caffeine (number needed to treat of 4 for pain relief 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 1, 3
• Effective oral triptans include sumatriptan 50-100 mg, rizatriptan 10 mg, naratriptan, or zolmitriptan 1, 3, 4
• If one triptan is ineffective after 2-3 attacks, try a different triptan as failure of one does not predict failure of others 1, 3
• For rapid progression or severe vomiting: Subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours) with onset within 15 minutes 1, 3

Managing Associated Symptoms

• Add antiemetic (metoclopramide 10 mg or prochlorperazine 10 mg) 20-30 minutes before analgesic for patients with nausea—this provides synergistic analgesia beyond treating nausea alone 1, 3
• Use non-oral routes (intranasal, subcutaneous, or IV) 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 at 2 hours) 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 formulation 1, 3

Contraindications to Triptans

Avoid triptans in patients with: 4, 5

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

Emergency Department/Urgent Care Treatment

For severe migraine requiring parenteral therapy: IV metoclopramide 10 mg + IV ketorolac 30 mg provides rapid relief with minimal rebound headache risk 3, 2

Alternative IV options: 3

• Prochlorperazine 10 mg IV (comparable efficacy to metoclopramide with 21% adverse event rate)
• Dihydroergotamine IV

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. 1, 3, 2

• Medication-overuse headache presents as daily or near-daily headaches and requires detoxification with temporary worsening before improvement 1, 4, 5
• If acute treatment is needed more than twice weekly, initiate preventive therapy immediately 1, 2

Medications to Avoid

• Never use opioids or butalbital-containing analgesics for routine migraine treatment—they lead to dependency, rebound headaches, and loss of efficacy 1, 3, 2
• Opioids should only be considered when all other evidence-based treatments have failed, contraindications exist, sedation is acceptable, and abuse risk has been addressed 3

Preventive Therapy Indications

Consider preventive therapy for patients with: 1, 2

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

First-Line Preventive Options

• Beta-blockers: Propranolol 80-240 mg/day or timolol 20-30 mg/day 1
• Topiramate: Effective but requires discussion of teratogenic effects with patients of childbearing potential 1
• OnabotulinumtoxinA 155 units: FDA-approved specifically for chronic migraine (≥15 headache days/month) 1
• CGRP monoclonal antibodies: For patients who fail oral preventives (assess efficacy after 3-6 months) 3

Lifestyle Modifications

Essential non-pharmacologic interventions: 1, 2

• Regular moderate-to-intense aerobic exercise 40 minutes three times weekly (as effective as some preventive medications)
• Maintain regular meals and adequate hydration
• Ensure consistent, sufficient sleep
• Stress management with relaxation techniques or mindfulness practices
• Cognitive-behavioral therapy and biofeedback (good evidence for efficacy)

Special Populations

Pregnancy

• First-line: Acetaminophen 1000 mg 2
• NSAIDs acceptable prior to third trimester 3, 2
• Avoid triptans, ergotamines, and valproate (teratogenic) 1

Pediatric Patients (6-17 years)

• Weight-based dosing: Rizatriptan 5 mg for patients 20-40 kg, 10 mg for ≥40 kg (33% pain-free at 2 hours vs 24% placebo) 4
• Acetaminophen and ibuprofen remain first-line for mild-to-moderate attacks 3

Common Pitfalls to Avoid

• Do not delay treatment—early administration while pain is mild significantly improves efficacy 1, 3, 2
• Do not allow escalating frequency of acute medication use—this creates medication-overuse headache; transition to preventive therapy instead 1, 3
• Do not assume all severe headaches are migraine—rule out secondary causes (thunderclap headache, progressive headache, fever with neck stiffness) before treating as migraine 3
• Do not give up after one triptan fails—try different triptans, different routes, or combination therapy before declaring triptan failure 1, 3