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 immediately to a triptan plus NSAID combination for moderate-to-severe attacks or when NSAIDs fail. 1

Acute Treatment Algorithm

Mild-to-Moderate Attacks (First-Line)

• NSAIDs are the initial choice: ibuprofen 400-800 mg, naproxen sodium 500-825 mg, aspirin 1000 mg, or diclofenac potassium 2, 1
• Alternative first-line option: aspirin-acetaminophen-caffeine combination (number needed to treat = 4 for pain relief at 2 hours) 1
• Acetaminophen 1000 mg can be used but has inferior efficacy compared to NSAIDs 1, 3
• Critical timing: Take medication as early as possible when headache is still mild to maximize effectiveness 1, 4

Moderate-to-Severe Attacks (Second-Line)

• Triptans are first-line for moderate-to-severe attacks: sumatriptan 50-100 mg, rizatriptan, naratriptan, or zolmitriptan 2, 1
• Combination therapy is superior: triptan plus NSAID (e.g., sumatriptan 50-100 mg + naproxen 500 mg) provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 1, 5
• Subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours) with onset within 15 minutes for rapid progression or severe vomiting 5, 4
• If one triptan fails, try a different triptan as failure of one does not predict failure of others 1, 5

Refractory Attacks (Third-Line)

• For patients failing all triptans or with triptan contraindications: CGRP antagonists (rimegepant, ubrogepant, zavegepant), lasmiditan, or dihydroergotamine 1, 3
• Rimegepant and ubrogepant have number needed to treat = 13 for pain freedom at 2 hours 1
• Lasmiditan has robust efficacy but significant adverse effects including driving restrictions (number needed to harm = 4) 1

Managing Associated Symptoms

Nausea and Vomiting

• Metoclopramide 10 mg IV/PO provides dual benefit: treats nausea and provides direct analgesic effects through central dopamine receptor antagonism 1, 5
• Prochlorperazine 10 mg IV/PO is equally effective as metoclopramide with comparable efficacy 1, 5
• Use non-oral routes (intranasal, subcutaneous, IV) when significant nausea or vomiting is present 1, 5

Emergency/Urgent Care Treatment

IV Combination Therapy

• First-line IV cocktail: metoclopramide 10 mg IV plus ketorolac 30 mg IV provides rapid relief with minimal rebound risk 1, 5
• Ketorolac has rapid onset with approximately 6 hours duration 1, 5
• Alternative IV option: dihydroergotamine (DHE) has good evidence as monotherapy 1, 5

Critical Medication Frequency Limits

Limit all acute medications to ≤2 days per week to prevent medication-overuse headache (MOH). 1, 5, 3

• NSAIDs: maximum 15 days per month 1, 3
• Triptans: maximum 10 days per month 1, 3
• Exceeding these limits leads to MOH, causing daily headaches and treatment resistance 2, 1
• If needing acute treatment >2 days/week, initiate preventive therapy immediately 1, 5

Preventive Therapy Indications

Consider preventive treatment when: 1

• ≥2 attacks per month producing disability lasting ≥3 days
• Contraindication to or failure of acute treatments
• Using acute medication >2 days per week
• Presence of 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, 5
• 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 failing oral preventives, assess efficacy after 3-6 months 1, 5

Medications to Avoid

Never use opioids or butalbital-containing analgesics for routine migraine treatment as they lead to dependency, rebound headaches, and loss of efficacy. 1, 5, 3

Special Populations

Pregnancy and Breastfeeding

• Acetaminophen is first-line for acute treatment 2, 1
• NSAIDs can be used prior to third trimester 3
• Avoid preventive treatment if possible 2
• Sodium valproate is absolutely contraindicated due to teratogenic risk 2, 1

Children and Adolescents

• Bed rest alone can be sufficient 2
• Ibuprofen for acute treatment 2
• Propranolol, amitriptyline, or topiramate for prevention 2

Older Adults

• Secondary headache, comorbidities, and adverse events are more likely 2
• Poor evidence base for all drugs in this age group 2

Lifestyle Modifications

Essential non-pharmacologic interventions: 1, 3

• Regular moderate-to-intense aerobic exercise (40 minutes, 3 times weekly) - as effective as some preventive medications 1
• Maintain regular meals and adequate hydration 1
• Ensure consistent, sufficient sleep 1
• Stress management with relaxation techniques or mindfulness 1
• Identify and reduce triggers using a headache diary 1, 5

Contraindications to Triptans

Triptans are contraindicated in: 4

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

Common Pitfalls to Avoid

• Taking medication too late in the attack - efficacy decreases significantly if not taken when pain is still mild 1, 4
• Using monotherapy when combination therapy is indicated - triptan plus NSAID is superior to either alone for moderate-to-severe attacks 1, 5
• Allowing patients to increase acute medication frequency rather than transitioning to preventive therapy 5
• Not recognizing medication-overuse headache - presents as daily headaches or marked increase in migraine frequency 2, 4