What are the recommended treatments for migraines?

Migraine Treatment

For acute migraine treatment, start with combination therapy of a triptan (sumatriptan 50-100 mg) plus an NSAID (naproxen 500 mg or ibuprofen 400-800 mg) for moderate to severe attacks, or an NSAID alone for mild attacks, taken as early as possible when pain is still mild. 1

First-Line Treatment Algorithm

Mild to Moderate Migraine

• Start with an NSAID monotherapy: ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg 1
• Acetaminophen 1000 mg is less effective and should only be used if NSAIDs are contraindicated 1
• If inadequate response after 2 hours, escalate to triptan therapy 1

Moderate to Severe Migraine

• Use combination therapy immediately: triptan + NSAID provides superior efficacy compared to either agent alone 1, 2
• Sumatriptan 50-100 mg PLUS naproxen 500 mg is the most evidence-based combination, with 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to placebo 2
• The 100 mg dose may provide greater effect than 50 mg (NNT 4.7 vs 6.1 for pain-free at 2 hours), though with higher adverse event rates 3, 4

Timing is Critical

• Treat early when pain is still mild - this provides significantly better outcomes than waiting until pain is moderate or severe 1, 4
• Triptans should NOT be taken during the aura phase, only once headache begins 1

Route Selection Based on Clinical Presentation

Severe Nausea or Vomiting Present

• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% pain-free at 2 hours, NNT 2.3) with onset within 15 minutes 2, 5
• Alternative: intranasal sumatriptan 20 mg (NNT 3.5) or intranasal zolmitriptan 1, 5
• Add antiemetic: metoclopramide 10 mg IV or prochlorperazine 10 mg IV/25 mg rectal 1, 2

Oral Route (No Significant Nausea)

• Sumatriptan 50-100 mg: 28% pain-free at 2 hours with 100 mg dose (NNT 6.1 for 50 mg) 3, 4
• If one triptan fails, try a different triptan - failure of one does not predict failure of others 1, 2

Second-Line Options (When Triptans Fail or Are Contraindicated)

CGRP Antagonists (Gepants)

• Rimegepant, ubrogepant, or zavegepant for patients who do not tolerate or have inadequate response to triptan + NSAID combination 1
• These have no vasoconstrictive effects, making them safe in cardiovascular disease 6

Ergot Alkaloids

• Dihydroergotamine (DHE) intranasal or IV for refractory cases 1, 2
• Contraindicated with concurrent triptan use, beta blockers, SSRIs, and in cardiovascular disease 7

Third-Line Option

• Lasmiditan (5-HT1F agonist) for patients who fail all other treatments 1

Critical Frequency Limitation

Limit ALL acute migraine medications to no more than 2 days per week (or 10 days per month for triptans, 15 days per month for NSAIDs) to prevent medication-overuse headache. 1, 2

• Medication-overuse headache causes paradoxical increase in headache frequency, potentially leading to daily headaches 1, 2
• If needing acute treatment more frequently, initiate preventive therapy immediately 1, 2

Contraindications Requiring Alternative Approach

Triptans Contraindicated In:

• Uncontrolled hypertension 1, 7
• Ischemic heart disease, previous MI, or significant cardiovascular disease 2, 7
• Basilar or hemiplegic migraine 7
• Pregnancy (discuss risks/benefits) 1

NSAIDs Contraindicated In:

• Renal impairment (CrCl <30 mL/min) 2
• Active GI bleeding or history of NSAID-induced GI bleeding 2
• Aspirin/NSAID-induced asthma 2

Medications to AVOID

Do not use opioids or butalbital-containing compounds for acute migraine treatment - these lead to dependency, medication-overuse headache, and loss of efficacy. 1, 2

Dosing for Recurrent Headache

• If migraine returns after initial response, a second dose of the same medication may be taken at least 2 hours after the first dose 3
• Maximum daily dose of sumatriptan: 200 mg in 24 hours 3
• Maximum naproxen: 1.5 g per day 2

When to Initiate Preventive Therapy

Preventive therapy is indicated when: 1, 2

• Two or more attacks per month producing disability lasting 3+ days
• Using acute medications more than 2 days per week
• Contraindication to or failure of acute treatments
• Patient preference to reduce attack frequency