What is the recommended treatment for a patient experiencing migraines?

Migraine Treatment

For acute migraine treatment, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) as first-line therapy for mild-to-moderate attacks, and use triptans (sumatriptan 50-100 mg, rizatriptan, or zolmitriptan) for moderate-to-severe attacks or when NSAIDs fail. 1

Acute Treatment Algorithm

First-Line: Mild-to-Moderate Attacks

• NSAIDs are the initial treatment of choice with the strongest evidence for aspirin, ibuprofen, naproxen sodium, and the acetaminophen-aspirin-caffeine combination 2, 1
• Acetaminophen alone is ineffective and should not be used as monotherapy 2
• Take medication early in the attack while pain is still mild to maximize effectiveness 1, 3
• Naproxen sodium 500-825 mg can be repeated every 2-6 hours as needed, maximum 1.5 g per day 1
• Adding an antiemetic (metoclopramide 10 mg or prochlorperazine 25 mg) 20-30 minutes before the NSAID provides synergistic analgesia 1

Second-Line: Moderate-to-Severe Attacks

• Triptans are first-line for moderate-to-severe migraine with good evidence for oral naratriptan, rizatriptan, sumatriptan, and zolmitriptan 2, 1
• Sumatriptan 50-100 mg orally achieves headache response in 52-62% at 2 hours and 65-79% at 4 hours 4
• Combination therapy (triptan + NSAID) is superior to either agent alone with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% complete pain relief by 2 hours) with onset within 15 minutes for rapid progression or severe attacks 1, 3
• Intranasal sumatriptan 5-20 mg is preferred when significant nausea or vomiting is present 1

Triptans are contraindicated in patients with uncontrolled hypertension, basilar or hemiplegic migraine, ischemic heart disease, or significant cardiovascular disease 2, 1

Third-Line: Refractory or Special Situations

• Intranasal dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy 2, 1
• IV metoclopramide 10 mg provides direct analgesic effects through central dopamine receptor antagonism, not just antiemetic benefit 1
• IV ketorolac 30 mg has rapid onset with approximately 6 hours duration and minimal rebound headache risk 1
• The combination of IV metoclopramide 10 mg plus IV ketorolac 30 mg is recommended as first-line IV therapy for severe attacks requiring emergency treatment 1
• Prochlorperazine 10 mg IV effectively relieves headache pain and is comparable to metoclopramide 1

Rescue Medications (Last Resort Only)

• Opioids should be reserved only when other medications cannot be used, sedation is not a concern, and abuse risk has been addressed 2, 1
• Butorphanol nasal spray has better evidence than other opioids if one must be used 1
• Avoid opioids and butalbital-containing compounds due to dependency risk, rebound headaches, and eventual loss of efficacy 1, 5

Critical Frequency Limitation

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, which paradoxically increases headache frequency and can lead to daily headaches 1, 5, 6

If using acute medications more frequently, initiate preventive therapy immediately rather than increasing acute medication frequency 1

Preventive Therapy Indications

Preventive therapy should be considered when: 2, 7

• Two or more migraine attacks per month producing disability for 3+ days per month 2, 7
• Using acute medications more than twice weekly 2, 7
• Failure of or contraindications to acute treatments 2, 7
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction) 2, 7

First-Line Preventive Medications

• Propranolol 80-240 mg/day or timolol 20-30 mg/day have the strongest evidence for efficacy with good tolerability 2, 7
• Topiramate 50-100 mg/day is particularly useful for patients with obesity due to associated weight loss 7
• Amitriptyline 30-150 mg/day is optimal for patients with comorbid depression, anxiety, or mixed migraine/tension-type headache 2, 7
• Divalproex sodium 500-1500 mg/day or sodium valproate 800-1500 mg/day are effective but strictly contraindicated in women of childbearing potential due to teratogenic effects 2, 7
• Candesartan is first-line for patients with comorbid hypertension 7

Implementation Strategy

• Start at a low dose and titrate slowly until clinical benefits are achieved or side effects limit further increases 7, 8
• Allow an adequate trial period of 2-3 months before determining efficacy 7, 8
• Track attack frequency, severity, and disability using headache diaries 7
• Consider tapering after 6-12 months of successful therapy to determine if discontinuation is possible 7

Third-Line: CGRP Monoclonal Antibodies

• Erenumab, fremanezumab, or galcanezumab should be considered when 2-3 oral preventive medications have failed or are contraindicated 7
• Efficacy requires 3-6 months for assessment 7
• Significantly more expensive ($5,000-$6,000 annually) than oral agents 7

Newer Alternatives (When Triptans Contraindicated)

• Gepants (ubrogepant 50-100 mg or rimegepant) are the primary oral alternative for moderate-to-severe migraine when triptans are contraindicated, with no vasoconstriction making them safe for cardiovascular disease 1
• Lasmiditan 50-200 mg is a 5-HT1F receptor agonist without vasoconstrictor activity, but patients must not drive for at least 8 hours after taking due to CNS effects 1

Special Population: Pregnancy

• Acetaminophen 1000 mg is first-line for acute treatment during pregnancy 9
• NSAIDs (ibuprofen) can be used only during the second trimester 9
• Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail 9
• Metoclopramide is safe for migraine-associated nausea during pregnancy 9
• Avoid NSAIDs in third trimester, triptans should be limited, and absolutely avoid ergotamines, opioids, butalbital, topiramate, candesartan, and valproate 9
• For preventive therapy if absolutely necessary, propranolol has the best safety data 9

Common Pitfalls to Avoid

• Not recognizing medication-overuse headache from frequent acute medication use (≥10 days/month for triptans, ≥15 days/month for NSAIDs) 1, 5
• Inadequate duration of preventive trial (less than 2-3 months) before declaring failure 7
• Starting preventive medications at too high a dose, leading to poor tolerability and discontinuation 7
• Allowing patients to increase acute medication frequency in response to treatment failure rather than transitioning to preventive therapy 1
• Using opioids or butalbital-containing compounds routinely, which creates dependency and rebound headaches 1, 5
• Not taking acute medications early enough in the attack when they are most effective 1, 3