What is the recommended treatment for a patient experiencing migraines?

Migraine Treatment Recommendations

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 use triptans (sumatriptan 50-100 mg, rizatriptan 10 mg, or zolmitriptan) for moderate-to-severe attacks or when NSAIDs fail. 1

Acute Treatment Algorithm

Mild-to-Moderate Migraine

• First-line: NSAIDs are the initial treatment of choice 1
  • Ibuprofen 400-800 mg 1
  • Naproxen sodium 500-825 mg 1
  • Aspirin 1000 mg 1
  • Combination: Aspirin + acetaminophen + caffeine 1
• Take medication early in the attack while pain is still mild for maximum effectiveness 1
• If NSAIDs fail after 2 hours, escalate to a triptan 1

Moderate-to-Severe Migraine

• First-line: Triptans are the primary treatment 1
  • Oral options: sumatriptan 50-100 mg, rizatriptan 10 mg, naratriptan, or zolmitriptan 1
  • Combination therapy (triptan + NSAID) is superior to either agent alone and represents the strongest recommendation 1
  • Example: Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either drug alone 1

Route Selection Based on Symptoms

• Oral route: Use when nausea is absent or mild 1
• Non-oral routes: Required when significant nausea or vomiting is present 1, 2
  • Subcutaneous sumatriptan 6 mg: Most effective option with 70-80% achieving relief within 1 hour and 59% pain-free by 2 hours 1, 3
  • Intranasal sumatriptan 5-20 mg 1
  • Rectal formulations 2

Add Antiemetic Therapy

• Metoclopramide 10 mg IV/oral provides both antiemetic effects and direct analgesic benefit through central dopamine receptor antagonism 1
• Prochlorperazine 10 mg IV is equally effective for headache pain and nausea 1
• Use antiemetics even when nausea is present without vomiting, as nausea itself is highly disabling 1
• Give antiemetics 20-30 minutes before NSAIDs for synergistic analgesia 1

Emergency Department/Urgent Care IV Treatment

The optimal IV cocktail is metoclopramide 10 mg IV + ketorolac 30 mg IV, providing rapid pain relief while minimizing rebound headache risk. 1

IV Treatment Components

• Ketorolac 30 mg IV (or 60 mg IM if <65 years old): Rapid onset with 6-hour duration 1
• Metoclopramide 10 mg IV: Provides both antiemetic and direct analgesic effects 1
• Alternative: Prochlorperazine 10 mg IV is comparable in efficacy to metoclopramide 1
• Second-line: Dihydroergotamine (DHE) IV or intranasal for refractory cases 1

What NOT to Use

• Avoid opioids (including hydromorphone) as they lead to dependency, rebound headaches, and loss of efficacy 1
• Avoid butalbital-containing compounds due to high risk of medication-overuse headache 1
• Prednisone has limited evidence for acute migraine and is more appropriate for status migrainosus 1

Critical Frequency Limitation

Limit ALL acute migraine medications to no more than 2 days per week to prevent medication-overuse headache (MOH). 1

• Using acute medications >2 days/week leads to increasing headache frequency and potentially daily headaches 1
• NSAIDs trigger MOH at ≥15 days/month 1
• Triptans trigger MOH at ≥10 days/month 1
• If patients need acute treatment more frequently, immediately initiate preventive therapy 1, 4

When to Initiate Preventive Therapy

Preventive therapy is indicated when: 4

• ≥2 migraine attacks per month producing disability lasting ≥3 days 4
• Using abortive medication more than twice per week 4
• Contraindication to or failure of acute treatments 4
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction) 4

First-Line Preventive Medications

• Propranolol 80-240 mg/day (strongest evidence) 4
• Timolol 20-30 mg/day 4
• Topiramate 100 mg/day (typically 50 mg twice daily) 4
• Candesartan (particularly useful with comorbid hypertension) 4

Second-Line Preventive Medications

• Amitriptyline 30-150 mg/day (especially for mixed migraine and tension-type headache) 4
• Valproate 800-1500 mg/day or divalproex sodium 500-1500 mg/day (strictly contraindicated in women of childbearing potential due to teratogenic effects) 4

Third-Line: CGRP Monoclonal Antibodies

• Erenumab, fremanezumab, galcanezumab, or eptinezumab when first- and second-line options fail 4
• Assess efficacy only after 3-6 months of treatment 4

Contraindications to Triptans

Triptans are contraindicated in: 1, 2

• Ischemic heart disease or previous myocardial infarction 1
• Uncontrolled hypertension 1
• Basilar or hemiplegic migraine 2
• Vasospastic coronary disease 1
• Significant cardiovascular disease 1

Common Pitfalls to Avoid

• Delaying treatment: Triptans work best when taken early while pain is still mild 1
• Monotherapy when combination is superior: Always consider triptan + NSAID combination for moderate-to-severe attacks 1
• Ignoring medication-overuse headache: Failure to recognize frequent acute medication use (>2 days/week) perpetuates the problem 1
• Using opioids routinely: This leads to dependency and worsening headache patterns 1
• Inadequate preventive trial duration: Preventive medications require 2-3 months for oral agents before assessing efficacy 4
• Wrong route selection: Oral medications are ineffective when significant nausea/vomiting is present 1, 2