What is the recommended treatment for an adult patient with migraines and no significant medical history?

Treatment of Migraine in Adults

Initial Acute Treatment Strategy

For adults with moderate to severe migraine, start with combination therapy of a triptan plus an NSAID, as this provides the most effective initial treatment with 130 additional patients per 1000 achieving sustained pain relief at 48 hours compared to triptan alone. 1

Mild to Moderate Attacks

• Begin with NSAIDs as first-line therapy, including ibuprofen, naproxen sodium, diclofenac potassium, or aspirin, which have the strongest evidence for efficacy 2, 1
• The combination of aspirin-acetaminophen-caffeine is an evidence-based alternative with good efficacy 2, 3
• Acetaminophen 1000 mg alone is less effective and should only be used when NSAIDs are contraindicated 1

Moderate to Severe Attacks

• Use triptans when NSAIDs fail or for attacks that begin with severe intensity 2
• Seven triptans have proven efficacy: sumatriptan, rizatriptan, zolmitriptan, naratriptan, almotriptan, eletriptan, and frovatriptan 3
• Take medication early in the attack when headache is still mild for maximum effectiveness 1
• Do not take triptans during the aura phase as they are ineffective at this stage 1

Managing Nausea and Vomiting

• Add an antiemetic (metoclopramide, prochlorperazine, or domperidone) for patients with significant nausea or vomiting 2, 3
• Consider non-oral routes of administration when nausea presents early in the attack 2
• Antiemetics should not be restricted only to patients who are vomiting, as nausea itself is disabling and warrants treatment 2

Second-Line Treatment for Refractory Attacks

When initial treatments fail to provide adequate relief:

CGRP Antagonists (Gepants)

• Consider rimegepant, ubrogepant, or zavegepant as the first alternative option for moderate to severe migraines not responding to NSAIDs and triptans 4
• These represent the most recent evidence-based recommendation from the American College of Physicians 2, 4

Dihydroergotamine (DHE)

• Use DHE, preferably in intranasal formulation, as the second alternative option 4
• DHE has good evidence for efficacy and safety in refractory migraines 2, 4
• DHE is contraindicated in patients with uncontrolled hypertension, coronary artery disease, or peripheral vascular disease 4

Lasmiditan

• Reserve lasmiditan for patients who don't tolerate or have inadequate response to all other treatments 4
• This ditan should be considered only when other pharmacologic options have failed 4

Medications to Avoid

Avoid opioids and butalbital-containing medications for migraine treatment due to risks of dependency, rebound headaches, and eventual loss of efficacy. 4, 1

Preventive Therapy Indications

Consider preventive treatment when patients have ≥2 attacks per month producing disability lasting ≥3 days per month. 1

Additional indications include:

• Use of acute medications more than twice weekly 1
• Contraindications to acute treatments 1
• Failure of acute treatments to provide adequate relief 2
• Presence of uncommon migraine variants (hemiplegic, basilar) 1

First-Line Preventive Medications

• Topiramate 50-100 mg daily has the strongest evidence, particularly for chronic migraine 1
• Amitriptyline 10-100 mg at night is effective, especially for patients with comorbid depression 1
• Propranolol 80-240 mg/day and timolol 20-30 mg/day have documented high efficacy 2
• Divalproex sodium 500-1500 mg/day has proven efficacy 2

Matching Preventive Therapy to Comorbidities

• Use amitriptyline for patients with depression and migraine 1
• Consider beta-blockers for patients with hypertension 2
• Match medication selection to the patient's comorbid conditions when possible 1

Non-Pharmacologic Interventions

Integrate cognitive-behavioral therapy, biofeedback and relaxation training, and regular aerobic exercise (40 minutes three times weekly) into comprehensive management. 1

Essential lifestyle modifications include:

• Adequate hydration 1
• Regular meals 1
• Consistent sleep patterns (sufficient and consistent sleep) 1
• Identification and avoidance of personal triggers 1

Critical Safety Considerations

Cardiovascular Screening for Triptans

• Perform cardiovascular evaluation in triptan-naive patients with multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD) before prescribing triptans 5
• Consider administering the first dose in a medically supervised setting with ECG monitoring for high-risk patients 5
• Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, or history of stroke/TIA 5

Medication Overuse Headache

• Limit acute treatment to less than 10 days per month for triptans and less than 15 days per month for NSAIDs to prevent medication overuse headache 5
• Overuse of acute medications can lead to exacerbation of headache and may present as migraine-like daily headaches 5
• Address medication overuse before concluding that preventive therapy has failed 1

Serotonin Syndrome Risk

• Monitor for serotonin syndrome when triptans are co-administered with SSRIs, SNRIs, TCAs, or MAO inhibitors 5
• Symptoms include mental status changes, autonomic instability, neuromuscular aberrations, and gastrointestinal symptoms 5
• Discontinue sumatriptan if serotonin syndrome is suspected 5

Common Pitfalls to Avoid

• Do not conclude treatment failure without addressing poor adherence, suboptimal dosing, medication overuse, or incorrect diagnosis 1
• Try other triptans if one fails, as individual response varies significantly 1
• Do not restrict antiemetics only to patients who are vomiting 2
• Ensure adequate trial duration (2-3 months) before declaring preventive therapy ineffective 2

Special Populations

Menstrual Migraine

• Use perimenstrual preventive treatment with long-acting NSAID (naproxen) or triptan (frovatriptan, naratriptan) for 5 days, beginning 2 days before expected menstruation 1
• Avoid combined hormonal contraceptives in migraine with aura due to increased stroke risk 1

Women of Childbearing Potential

• Discuss adverse effects of pharmacologic treatments during pregnancy and lactation with all women of childbearing potential 4
• Document these discussions in the medical record 4