What are the treatment options for a patient experiencing migraines?

Migraine Treatment

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) or the combination of aspirin-acetaminophen-caffeine; for moderate to severe attacks, use a triptan (sumatriptan 50-100 mg, rizatriptan, or zolmitriptan) combined with an NSAID for superior efficacy. 1, 2, 3

Stratified Treatment Algorithm

Mild to Moderate Migraine

• First-line: NSAIDs are the initial treatment of choice 1, 3
  • Ibuprofen 400-800 mg 1
  • Naproxen sodium 500-825 mg 1
  • Aspirin 1000 mg 2
  • Aspirin-acetaminophen-caffeine combination (highly effective with NNT of 4 for pain relief at 2 hours) 2
• Timing: Administer as early as possible during the attack to improve efficacy 4, 1
• Alternative: Acetaminophen 1000 mg is less effective than NSAIDs but acceptable for patients intolerant of NSAIDs 2, 3

Moderate to Severe Migraine

• First-line: Triptan + NSAID combination therapy 1, 2
  • Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg provides superior efficacy compared to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1
  • Alternative triptans: rizatriptan, zolmitriptan, naratriptan 4, 1
• Monotherapy option: Triptans alone if NSAIDs are contraindicated 1, 2
  • Sumatriptan 50-100 mg achieves headache response in 50-62% at 2 hours and 65-79% at 4 hours 5
  • If one triptan fails, try another as failure of one does not predict failure of others 2

Severe Migraine with Nausea/Vomiting

• Use non-oral routes when significant nausea or vomiting is present 4, 1
• IV combination therapy: Metoclopramide 10 mg IV + ketorolac 30 mg IV 1
  • Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism, not just antiemetic effects 1
  • Ketorolac has rapid onset with 6-hour duration and minimal rebound headache risk 4, 1
• Alternative: Prochlorperazine 10 mg IV effectively relieves headache pain 4, 1
• Subcutaneous option: Sumatriptan 6 mg subcutaneous provides highest efficacy with 59% achieving complete pain relief by 2 hours and onset within 15 minutes 1
• Intranasal option: Sumatriptan 5-20 mg nasal spray or other intranasal triptans 1

Second-Line and Rescue Treatments

When First-Line Treatments Fail

• CGRP antagonists (gepants): Rimegepant, ubrogepant, or zavegepant 1, 3
  • NNT of 13 for pain freedom at 2 hours 2
• Dihydroergotamine (DHE): Intranasal or IV formulation has good evidence for efficacy 4, 1
• Lasmiditan (ditan): Reserved for patients who don't respond to all other treatments, but has significant adverse effects including driving restrictions 2, 3

Adjunctive Therapy for Associated Symptoms

• Antiemetics treat nausea and provide synergistic analgesia 4, 1
  • Metoclopramide 10 mg (oral, IV, or IM) 4, 1
  • Prochlorperazine 10-25 mg (oral, IV, or rectal) 4, 1
• Administer antiemetics 20-30 minutes before analgesics to improve gastric motility and medication absorption 1

Critical Medication Frequency Limits

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, 3

• Medication-overuse headache presents as daily headaches or marked increase in migraine frequency 4, 1
• If patients require acute treatment more than twice weekly, initiate preventive therapy immediately 1, 2

Medications to Avoid

Never use opioids (hydromorphone, meperidine, oxycodone) or butalbital-containing compounds for routine migraine treatment. 4, 1, 2, 3

• Opioids lead to dependency, rebound headaches, and eventual loss of efficacy 4, 1
• 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 1
• Butorphanol nasal spray has better evidence than other opioids if an opioid must be used 1

Contraindications and Safety Considerations

Triptan Contraindications

• Absolute contraindications: Ischemic heart disease, coronary artery disease, Prinzmetal's variant angina, uncontrolled hypertension, history of stroke or TIA, Wolff-Parkinson-White syndrome 5
• Cardiovascular risk: Triptans cause vasoconstriction and should not be used in patients with cardiovascular disease 3, 5
• Serotonin syndrome risk: Use caution when combining with SSRIs, SNRIs, TCAs, or MAO inhibitors 5

NSAID Precautions

• Ketorolac should be used with caution in renal impairment, history of GI bleeding, or heart disease 1
• Monitor for medication-overuse headache with frequent NSAID use 4, 1

Pregnancy Considerations

• Acetaminophen is the safest first-line option during pregnancy 3, 6
• Sumatriptan may be an option for selected pregnant patients and is compatible with breastfeeding 6

When to Initiate Preventive Therapy

Start preventive therapy if patients have: 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
• 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
• Topiramate: Effective but requires discussion of teratogenic effects with patients of childbearing potential 2
• OnabotulinumtoxinA 155 units: FDA-approved for chronic migraine (≥15 headache days per month) 2
• CGRP monoclonal antibodies: Consider when oral preventives fail, with efficacy assessed after 3-6 months 1

Common Pitfalls to Avoid

• Don't wait for severe pain to develop before treating—early administration improves efficacy 4, 1, 2
• Don't use acetaminophen alone for migraine—it has limited efficacy as monotherapy but works well in combination with aspirin and caffeine 4, 2
• Don't allow patients to increase acute medication frequency in response to treatment failure—this creates medication-overuse headache; instead transition to preventive therapy 1
• Don't assume all triptans are the same—if one triptan fails, try another as response varies between agents 2
• Don't use prednisone routinely for acute headache in urgent care—it has limited evidence and is more appropriate for status migrainosus 1