What are the recommended treatment options for a patient experiencing migraines?

Migraine Treatment

Acute Treatment Algorithm

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 or when NSAIDs fail, escalate immediately to triptans combined with an NSAID, as this combination provides superior efficacy compared to either agent alone. 1, 2

First-Line Treatment for Mild to Moderate Attacks

• NSAIDs are the initial treatment of choice, with strongest evidence supporting aspirin, ibuprofen, naproxen sodium, and tolfenamic acid 3
• The aspirin-acetaminophen-caffeine combination has a number needed to treat of 9 for pain freedom at 2 hours and 4 for pain relief at 2 hours 2
• Acetaminophen alone is ineffective and should not be used as monotherapy 3, 2
• Take medication as early as possible during the attack while pain is still mild to maximize effectiveness 1, 2

Escalation to Triptan Therapy

• Triptans should be used when NSAIDs provide inadequate relief or for moderate to severe attacks 3, 1
• Oral triptans with good evidence include naratriptan, rizatriptan, sumatriptan, and zolmitriptan 3, 1
• Combining a triptan with an NSAID is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1, 2
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% complete pain relief by 2 hours) with onset within 15 minutes, making it ideal for rapid progression or significant vomiting 1, 4

Contraindications to Triptans

• Do not use triptans in patients with uncontrolled hypertension, ischemic heart disease, previous myocardial infarction, basilar or hemiplegic migraine, history of stroke or transient ischemic attack, or Wolff-Parkinson-White syndrome 3, 4, 5
• Perform cardiovascular evaluation in triptan-naïve patients with multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD) before prescribing triptans 4, 5
• If one triptan fails, try a different triptan before abandoning the class, as failure of one does not predict failure of others 1, 2

Third-Line Acute Treatment Options

• For patients who fail all triptans or have contraindications, use CGRP antagonists (gepants) such as ubrogepant 50-100 mg or rimegepant 1, 2
• Gepants have no vasoconstriction and are safe for patients with cardiovascular disease, with a number needed to treat of 13 for pain freedom at 2 hours 1, 2
• Lasmiditan (ditan) 50-200 mg is an alternative 5-HT1F receptor agonist without vasoconstrictor activity, but patients must not drive for at least 8 hours after taking it due to CNS effects 1
• Intranasal or IV dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy 3, 1

Managing Associated Symptoms

• Use non-oral routes of administration (intranasal, subcutaneous, IV, or rectal) when significant nausea or vomiting is present early in the attack 3, 1
• Add an antiemetic (metoclopramide 10 mg IV or prochlorperazine 10 mg IV) 20-30 minutes before other medications, as these provide synergistic analgesia beyond their antiemetic effects 1
• For IV treatment in urgent care settings, use the combination of ketorolac 30 mg IV plus metoclopramide 10 mg IV as first-line therapy 1

Critical Medication Frequency Limits

• Strictly limit all acute migraine medications to no more than 2 days per week (10 days per month for triptans, 15 days per month for NSAIDs) to prevent medication-overuse headache 1, 2, 4, 5
• Medication-overuse headache presents as migraine-like daily headaches or marked increase in attack frequency 1, 4, 5
• If patients require acute treatment more than twice weekly, initiate preventive therapy immediately 1, 2

Medications to Avoid

• Do not use opioids (including hydromorphone) or butalbital-containing compounds for migraine treatment, as they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time 3, 1, 2
• Opioids should only be considered as last resort when all other evidence-based treatments have failed or are contraindicated, sedation is not a concern, and risk for abuse has been addressed 3, 1
• If an opioid must be used, butorphanol nasal spray has better evidence than other opioids specifically for headache treatment 1

Preventive Therapy Indications

Initiate preventive therapy for patients with two or more migraine attacks per month producing disability lasting 3 or more days, use of acute medication more than twice per week, contraindication to or failure of acute treatments, or presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura). 3, 2

First-Line Preventive Medications

• Beta-blockers without intrinsic sympathomimetic activity (propranolol 80-240 mg/day or timolol 20-30 mg/day) have consistent evidence of efficacy 1, 2
• Topiramate and divalproex sodium/sodium valproate are effective first-line options, but discuss teratogenic effects with patients of childbearing potential 2
• Amitriptyline 30-150 mg/day is recommended for patients with mixed migraine and tension-type headache 1
• CGRP monoclonal antibodies should be considered when oral preventives have failed or are contraindicated, with efficacy assessed after 3-6 months 1

Chronic Migraine Specific Treatment

• OnabotulinumtoxinA 155 units is FDA-approved and effective specifically for chronic migraine (≥15 headache days per month), with efficacy assessed after 6-9 months 1, 2
• Rule out medication-overuse headache before establishing chronic migraine diagnosis 2

Preventive Therapy Monitoring

• Start preventive medications at a low dose and gradually increase until desired outcomes are achieved 2
• Use a headache diary to monitor treatment efficacy, identify analgesic overuse, and follow migraine progression 2
• Give each preventive treatment an adequate trial (2-3 months for oral agents, 3-6 months for CGRP antibodies, 6-9 months for onabotulinumtoxinA) before switching 1

Non-Pharmacological Approaches

Evidence-Based Lifestyle Modifications

• Maintain adequate hydration and eat regular meals without skipping 6, 2
• Ensure sufficient and consistent sleep (7-9 hours nightly) 6, 2
• Engage in regular moderate to intense aerobic exercise (40 minutes three times weekly), which is as effective as some preventive medications 6, 2
• Practice stress management with relaxation techniques or mindfulness 6, 2
• Pursue weight loss if overweight or obese 6

Behavioral Treatments

• Cognitive-behavioral therapy, biofeedback, and relaxation training should be offered to all patients as part of comprehensive management 2
• These behavioral treatments have good evidence for efficacy and should be combined with pharmacological approaches 2

Dietary Considerations

• There is insufficient evidence to recommend routine dietary trigger avoidance or elimination diets for migraine prevention 6
• Use a headache diary to track potential food triggers alongside other factors (stress, sleep, hormonal changes) rather than implementing blanket dietary restrictions 6
• Do not use IgG antibody testing for dietary trigger identification 6

Supplements with Evidence

• Magnesium, riboflavin (vitamin B2), and coenzyme Q10 have shown efficacy in more than one randomized trial and can be considered as first-line preventive interventions 2, 7
• These supplements are particularly useful when patients prefer natural treatments or have contraindications to prescription medications 7

Common Pitfalls to Avoid

• Do not allow patients to increase frequency of acute medication use in response to treatment failure, as this creates a vicious cycle of medication-overuse headache; instead transition to preventive therapy while optimizing acute treatment strategy 1
• Do not restrict metoclopramide only to patients who are vomiting, as nausea itself is one of the most disabling symptoms and warrants treatment 1
• Do not assume all triptans will fail if one triptan is ineffective; try different triptans with adequate trials before escalating to third-line agents 1
• Do not use prednisone or corticosteroids for routine acute headache treatment, as they have limited evidence and are more appropriate for status migrainosus 1