What are the treatment options for a patient experiencing migraines?

Migraine Treatment

For acute migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) for mild-to-moderate attacks, and escalate to a triptan combined with an NSAID for moderate-to-severe attacks or when NSAIDs alone fail. 1

First-Line Treatment Algorithm

Mild to Moderate Attacks

• Begin with NSAIDs as first-line therapy, specifically aspirin, ibuprofen, naproxen sodium, or diclofenac potassium, which have demonstrated efficacy and favorable tolerability 1
• The aspirin-acetaminophen-caffeine combination (such as Excedrin Migraine) is highly effective with a number needed to treat of 9 for pain freedom at 2 hours 2
• Take medication as early as possible during the attack while pain is still mild to maximize effectiveness 1, 2

Moderate to Severe Attacks

• Combine a triptan with an NSAID from the onset, as this combination is superior to either agent alone and represents the strongest recommendation from current guidelines 1, 2
• Oral triptans with strong evidence include sumatriptan 50-100 mg, rizatriptan, naratriptan, and zolmitriptan 1
• The combination of sumatriptan 85 mg plus naproxen sodium 500 mg (Treximet) provides 65% pain relief at 2 hours and 25% sustained pain-free response through 24 hours 3
• If one triptan fails, try a different triptan before abandoning this class, as failure of one does not predict failure of others 1, 2

Route Selection Based on Symptoms

Patients with Significant Nausea/Vomiting

• Use non-oral routes: subcutaneous sumatriptan 6 mg provides the highest efficacy with 59% achieving complete pain relief by 2 hours and onset within 15 minutes 1
• Intranasal sumatriptan (5-20 mg) or intranasal zolmitriptan are alternatives 1
• Add an antiemetic 20-30 minutes before oral medications: metoclopramide 10 mg or prochlorperazine 10 mg provide synergistic analgesia beyond their antiemetic effects 1

Second-Line and Rescue Options

When First-Line Treatments Fail

• Intranasal dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy 1
• Newer CGRP antagonists (gepants) including rimegepant, ubrogepant, or zavegepant are options when triptans are contraindicated or ineffective, though with modest benefit (number needed to treat of 13) 2
• Lasmiditan (ditan) demonstrated robust benefit but has significant adverse effects including driving restrictions 2

IV Treatment for Severe Refractory Attacks

• Metoclopramide 10 mg IV plus ketorolac 30 mg IV is the recommended first-line IV combination, providing rapid pain relief with minimal rebound headache risk 1
• Prochlorperazine 10 mg IV is equally effective to metoclopramide and may be substituted 1

Critical Medication Frequency Limits

Strictly limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 1, 2

• NSAIDs trigger medication-overuse headache at ≥15 days/month 1
• Triptans trigger medication-overuse headache at ≥10 days/month 1
• If using acute medications more than twice weekly, initiate preventive therapy immediately 1

Medications to Avoid

• Avoid opioids (including hydromorphone and oxycodone combinations) for migraine treatment, as they lead to dependency, rebound headaches, and eventual loss of efficacy 1, 3
• Avoid butalbital-containing compounds for routine use 1, 2
• Reserve opioids only for cases where all other medications are contraindicated, sedation is not a concern, and abuse risk has been addressed 1

Important Contraindications and Cautions

Triptan Contraindications

• Do not use triptans in patients with ischemic heart disease, previous myocardial infarction, uncontrolled hypertension, or significant cardiovascular disease, as sumatriptan can cause coronary artery vasospasm 3
• Serious cardiac events including acute myocardial infarction and life-threatening arrhythmias have been reported within hours of triptan administration 3
• Cerebrovascular events including stroke and cerebral hemorrhage have been reported with triptans 3

NSAID Cautions

• NSAIDs increase risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, particularly in patients with known cardiovascular disease 3
• Use caution in patients with renal impairment, history of GI bleeding, or heart disease 1
• Monitor blood pressure, as NSAIDs can cause new-onset hypertension or worsen preexisting hypertension 3

Serotonin Syndrome Risk

• When combining triptans with SSRIs or SNRIs, monitor carefully for serotonin syndrome symptoms including mental status changes, autonomic instability, and neuromuscular aberrations 3

When to Initiate Preventive Therapy

Preventive therapy is indicated when 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 include propranolol 80-240 mg/day, topiramate, or CGRP monoclonal antibodies for chronic migraine (≥15 headache days/month) 1, 2

Pregnancy Considerations

• Acetaminophen is the safest acute migraine medication during pregnancy 4
• Sumatriptan may be an option for selected pregnant patients and is compatible with breastfeeding 4
• Avoid NSAIDs, particularly in the third trimester 4