What are the treatment options for a patient experiencing migraines?

Migraine Headache Management

Acute Treatment Strategy

For acute migraine attacks, start with NSAIDs or aspirin-acetaminophen-caffeine combination for mild-to-moderate attacks, escalate to triptans for moderate-to-severe attacks or when NSAIDs fail, and reserve gepants (rimegepant, ubrogepant) or lasmiditan for triptan failures or contraindications. 1

First-Line Acute Treatment

• Begin with aspirin-acetaminophen-caffeine combination (number needed to treat = 4 for pain relief at 2 hours), which has the strongest evidence as first-line therapy for mild-to-moderate migraine. 1
• Alternative NSAIDs with proven efficacy include ibuprofen 400-800 mg every 6 hours, naproxen sodium 275-550 mg every 2-6 hours, or aspirin 650-1000 mg every 4-6 hours. 2
• Paracetamol (acetaminophen) alone has inferior efficacy and should only be used when NSAIDs are contraindicated. 1

Second-Line: Triptans

• Prescribe triptans when over-the-counter analgesics provide inadequate relief, and instruct patients to take them early in the attack while headache is still mild for maximum efficacy. 1, 3
• Sumatriptan tablets (25 mg, 50 mg, or 100 mg) achieve headache response (reduction to mild or no pain) in 52-62% of patients at 2 hours and 65-79% at 4 hours, compared to 17-27% and 19-38% with placebo. 3
• If one triptan fails, trial a different triptan as individual response varies. 1
• Combine a triptan with an NSAID or acetaminophen to improve efficacy beyond either agent alone. 1
• Use subcutaneous sumatriptan injection for patients with severe vomiting who cannot tolerate oral medications. 1

Third-Line: Advanced Options

• For patients who fail all triptans or have cardiovascular contraindications, use CGRP antagonists (gepants) like rimegepant or ubrogepant (number needed to treat = 13), zavegepant nasal spray, lasmiditan (ditan), or dihydroergotamine. 1, 2
• Note that lasmiditan has significant adverse effects including driving restrictions and a number needed to harm of 4 for treatment-emergent adverse effects. 1

Managing Associated Symptoms

• Administer antiemetics (metoclopramide or prochlorperazine) for nausea and to improve gastric motility, which enhances absorption of oral medications. 1, 2
• Use non-oral routes (nasal spray, subcutaneous injection, suppository) when nausea and vomiting are prominent. 1

Critical Medication Overuse Prevention

• Strictly limit acute medication use to ≤10 days per month for triptans and ≤15 days per month for NSAIDs to prevent medication overuse headache. 1
• Avoid opioids and butalbital-containing analgesics entirely as they increase risk of medication overuse headache, dependency, and have limited efficacy evidence. 1, 2

Preventive Treatment Indications

Initiate preventive therapy when patients experience ≥2 attacks per month producing disability lasting ≥3 days per month, use acute medications more than twice weekly, have contraindications to acute treatments, or suffer from uncommon migraine variants (hemiplegic migraine, prolonged aura). 1

First-Line Preventive Medications

• For episodic migraine, prescribe topiramate, beta-blockers (propranolol, metoprolol, timolol), or amitriptyline as first-line agents with documented high efficacy. 4, 5, 6
• Start at low doses and titrate gradually until desired outcomes are achieved. 1
• For chronic migraine (≥15 headache days per month), topiramate is the only oral medication proven effective in randomized placebo-controlled trials specifically for this population. 4
• Counsel patients of childbearing potential about topiramate's teratogenic effects before prescribing. 1

Second-Line Preventive Options

• Consider ACE inhibitors (lisinopril), ARBs (candesartan), or SSRIs if first-line treatments are not tolerated or produce inadequate response. 1, 5
• Valproic acid/divalproex has documented efficacy but carries teratogenic risk. 4, 6

Chronic Migraine-Specific Treatment

• OnabotulinumtoxinA 155 units is the only FDA-approved therapy specifically for chronic migraine prophylaxis (≥15 headache days per month), based on large-scale Phase III trials showing reduction in headache days, episodes, cumulative hours, and severity. 4, 1
• This should be administered by a neurologist or headache specialist using the standardized protocol. 4

Newer Preventive Options

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) are effective for patients who have failed multiple traditional preventive medications. 2, 5

Non-Pharmacologic Treatments

Offer cognitive-behavioral therapy, biofeedback, and relaxation training to all migraine patients as these have good evidence for efficacy and should be integrated into comprehensive management. 4, 1

Behavioral Interventions

• Implement relaxation training, meditative therapy with abdominal breathing exercises, progressive muscle relaxation, and visualization/guided imagery. 4
• Cognitive-behavioral therapy helps patients modify responses to stressful life events and reduces medication overuse. 4

Exercise and Lifestyle

• Prescribe regular moderate-to-intense aerobic exercise for 40 minutes three times weekly, which is as effective as topiramate or relaxation therapy for migraine prevention. 4, 1
• Maintain regular sleep schedules with sufficient sleep duration. 1
• Eat regular meals, stay well-hydrated, and avoid prolonged fasting. 1
• Manage stress with relaxation techniques or mindfulness practices. 1

Supplements with Evidence

• Magnesium citrate, riboflavin (vitamin B2), and coenzyme Q10 have favorable efficacy and safety profiles for migraine prevention. 1, 5, 7

Identifying and Managing Triggers

• Require patients to maintain a headache diary to accurately document headache frequency (many patients underreport milder headaches), identify triggers, monitor analgesic overuse, and assess treatment efficacy. 4, 1
• Address modifiable risk factors including obesity, obstructive sleep apnea, psychiatric comorbidities (depression, anxiety), and caffeine overuse. 4
• Identify food triggers through detailed nutritional history, with particular attention to phenylethylamine, tyramine, aspartame, monosodium glutamate, nitrates/nitrites, alcohol, and excessive caffeine. 7

Chronic Migraine Diagnosis and Management

• Diagnose chronic migraine when patients experience ≥15 headache days per month (each lasting ≥4 hours), with ≥8 days per month having migraine features. 4
• Ask directly: "Do you feel like you have a headache of some type on 15 or more days per month?" as patients often fail to report milder headache days. 4
• Rule out secondary causes of headache before establishing chronic migraine diagnosis. 4, 1
• Every chronic migraine treatment plan must include both prophylactic treatment to reduce headache frequency/severity AND as-needed treatment for acute exacerbations. 4

Comorbidity Management

• Treat comorbid conditions (depression, anxiety, sleep disorders, hypertension, obesity) with medications that also benefit migraine when possible—for example, amitriptyline for depression and migraine, or beta-blockers for hypertension and migraine. 4, 2

Monitoring and Follow-Up

• Monitor treatment efficacy using headache diaries and validated tools (HIT-6, Migraine-Specific Quality-of-Life Questionnaire). 4
• Switch preventive treatment if adequate response is not achieved during a reasonable trial period (typically 2-3 months at therapeutic dose). 1
• Set realistic expectations: chronic migraine recovery is often gradual and requires multimodal therapy. 4

Critical Safety Considerations for Triptans

• Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's angina, Wolff-Parkinson-White syndrome, uncontrolled hypertension, history of stroke or TIA, and hemiplegic or basilar migraine. 3
• Perform cardiac evaluation in high-risk patients who experience chest, throat, neck, or jaw pain/tightness/pressure after triptan use, as these symptoms are usually non-cardiac but require exclusion of coronary vasospasm. 3
• Monitor for serotonin syndrome when combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors. 3
• Use triptans with caution in patients with cardiovascular risk factors or history of seizures. 2, 3