What are the treatment options for migraine management?

Migraine Management

Acute Treatment Algorithm

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, aspirin 1000 mg, or diclofenac potassium) as first-line therapy, and escalate to triptans for moderate to severe attacks or when NSAIDs fail after 2-3 attempts. 1, 2

First-Line Treatment by Attack Severity

Mild to Moderate Attacks:

• NSAIDs are the initial choice, with strongest evidence for aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 2
• Aspirin-acetaminophen-caffeine combination (e.g., Excedrin Migraine) is highly effective with a number needed to treat of 4 for pain relief at 2 hours 3
• Acetaminophen 1000 mg has less efficacy than NSAIDs and should only be used when NSAIDs are contraindicated 3

Moderate to Severe Attacks:

• Triptans are first-line therapy when NSAIDs provide inadequate relief or for severe attacks from the outset 1, 2
• Combination therapy (triptan + NSAID) is superior to either agent alone and represents the strongest recommendation, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 2, 3
• Administer triptans early in the attack while headache is still mild for maximum effectiveness 1, 2

Triptan Selection and Optimization

Route Selection Based on Clinical Features:

• Oral triptans (sumatriptan 50-100 mg, rizatriptan, eletriptan, zolmitriptan, naratriptan, almotriptan) for standard attacks 1, 4
• Subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours) with onset within 15 minutes, ideal for rapid progression or severe vomiting 2, 5
• Intranasal formulations (sumatriptan 5-20 mg, zolmitriptan) for patients with significant nausea or vomiting 2, 5

Critical Triptan Principles:

• If one triptan fails, try a different triptan—failure of one does not predict failure of others 2, 4
• Maximum of 2 doses in 24 hours for any triptan 2
• Triptans are contraindicated in ischemic heart disease, uncontrolled hypertension, previous stroke/TIA, or peripheral vascular disease 6

Second-Line and Rescue Options

For Triptan Failures or Contraindications:

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant have no vasoconstrictive effects, making them safe for cardiovascular disease patients 2, 3, 7
• Lasmiditan (ditan): 5-HT1F agonist without vasoconstriction, but requires 8-hour driving restriction due to CNS effects 3, 7
• Dihydroergotamine (DHE): intranasal or IV formulation with good efficacy, but contraindicated in cardiovascular disease 2, 5

Antiemetics as Adjunctive or Monotherapy:

• Metoclopramide 10 mg IV provides direct analgesic effects beyond antiemetic properties through central dopamine receptor antagonism 2, 5
• Prochlorperazine 10 mg IV is comparable to metoclopramide in efficacy with a favorable side effect profile 2, 5
• Both can be used 20-30 minutes before oral medications to enhance absorption 2

Emergency Department/Severe Refractory Attacks

Optimal IV "Headache Cocktail":

• Metoclopramide 10 mg IV + ketorolac 30 mg IV is the first-line combination for severe attacks requiring parenteral treatment 2
• Ketorolac has rapid onset with 6-hour duration and minimal rebound headache risk 2, 5
• Alternative: DHE IV for patients with NSAID contraindications 2

Medications to Avoid:

• Opioids (including hydromorphone) should be reserved only when all other options have failed, as they lead to dependency, medication-overuse headache, and loss of efficacy 2, 5
• Butalbital-containing compounds carry similar risks 3, 4

Critical Frequency Limitation to Prevent Medication-Overuse Headache

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

• NSAIDs and combination analgesics: ≤15 days/month triggers medication-overuse headache 2
• Triptans: ≥10 days/month triggers medication-overuse headache 2
• If patients need acute treatment more than twice weekly, initiate preventive therapy immediately 1, 2

Preventive Treatment Indications

Consider preventive medications when patients have: 1

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

First-Line Preventive Options

Beta-blockers: 1

• Propranolol 80-240 mg/day or timolol 20-30 mg/day have strongest evidence

Topiramate: 1, 3

• Effective but requires discussion of teratogenic effects with patients of childbearing potential
• Contraindicated in pregnancy

Candesartan (ARB): 1

• Alternative for patients intolerant to beta-blockers

OnabotulinumtoxinA 155 units: 3

• FDA-approved specifically for chronic migraine (≥15 headache days/month)
• Requires 6-9 months to assess efficacy

CGRP monoclonal antibodies: 2

• Consider when oral preventives fail or are contraindicated
• Assess efficacy after 3-6 months

Non-Pharmacologic Interventions

Lifestyle Modifications (Essential for All Patients): 1, 3

• Maintain regular meals and adequate hydration
• Consistent sleep schedule (same bedtime/wake time daily)
• Regular aerobic exercise 40 minutes three times weekly (as effective as some preventive medications) 3
• Stress management techniques including relaxation training or mindfulness

Behavioral Therapies with Evidence: 1, 3

• Cognitive-behavioral therapy
• Thermal biofeedback combined with relaxation
• Electromyographic biofeedback
• These should be offered to all patients as part of comprehensive management 3

Neuromodulation: 7

• Remote electrical neuromodulation has strongest evidence for acute treatment
• Non-pharmacologic option for patients with medication contraindications

Monitoring and Follow-Up

Headache Diary Requirements: 1, 3

• Track severity, frequency, duration, disability, treatment response, and adverse effects
• Essential for determining treatment efficacy and identifying medication overuse
• Use to identify triggers and patterns

Special Populations

Pregnancy and Lactation: 2

• Topiramate and valproate are strictly contraindicated due to teratogenic risk
• Discuss risks of all pharmacologic treatments before initiating therapy
• Consider non-pharmacologic options as primary approach

Cardiovascular Disease Patients: 7

• Gepants (rimegepant, ubrogepant, zavegepant) and lasmiditan are safe alternatives without vasoconstrictive effects
• Triptans and ergot derivatives are contraindicated 6

Elderly Patients: 6

• Blood pressure elevations are more pronounced in elderly patients with triptans
• Reduce ketorolac dose to 30 mg IV for patients ≥65 years 2