What are the treatment options for a patient experiencing migraines?

Migraine Treatment

For acute migraine treatment, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin-acetaminophen-caffeine combination) for mild-to-moderate attacks, and escalate immediately to a triptan plus NSAID combination for moderate-to-severe attacks or when NSAIDs alone fail. 1, 2

Acute Treatment Algorithm

Mild-to-Moderate Attacks

• First-line: Use NSAIDs at migraine onset while pain is still mild 1, 2

  • Ibuprofen 400-800 mg 1
  • Naproxen sodium 500-825 mg (can repeat every 2-6 hours, maximum 1.5 g/day) 1
  • Aspirin-acetaminophen-caffeine combination (number needed to treat of 4 for pain relief at 2 hours) 2

• Adjunctive therapy: Add metoclopramide 10 mg or prochlorperazine 25 mg orally 20-30 minutes before the NSAID to provide synergistic analgesia and improve gastric absorption 1

Moderate-to-Severe Attacks

• First-line combination therapy: Triptan PLUS NSAID taken together at attack onset 1, 2

  • Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 1
  • This combination is superior to monotherapy and represents the strongest current recommendation 1, 2

• Alternative triptans if sumatriptan fails: Try a different triptan, as failure of one does not predict failure of others 1

  • Oral options: rizatriptan, zolmitriptan, naratriptan 1
  • Subcutaneous sumatriptan 6 mg for rapid progression or severe vomiting (59% pain-free at 2 hours, onset within 15 minutes) 1
  • Intranasal sumatriptan 5-20 mg when significant nausea/vomiting prevents oral administration 1

Refractory or Triptan-Contraindicated Cases

• CGRP antagonists (gepants): First choice when triptans fail or are contraindicated due to cardiovascular disease 1, 2

  • Ubrogepant 50-100 mg or rimegepant (number needed to treat of 13 for pain freedom) 2
  • No vasoconstriction, safe in cardiovascular disease, uncontrolled hypertension, or cerebrovascular disease 1

• Lasmiditan (ditan): 50-200 mg for patients with cardiovascular contraindications to triptans 1, 2

  • Critical warning: Patients cannot drive or operate machinery for at least 8 hours due to CNS effects (dizziness, vertigo, somnolence) 1

• Dihydroergotamine (DHE): Intranasal or IV formulation has good efficacy as monotherapy 1

IV Treatment for Severe Attacks (Emergency/Urgent Care Setting)

• Optimal IV cocktail: Metoclopramide 10 mg IV PLUS ketorolac 30 mg IV 1

  • Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism, not just antiemetic benefit 1
  • Ketorolac has rapid onset with 6-hour duration and minimal rebound headache risk 1

• Alternative IV option: Prochlorperazine 10 mg IV (comparable efficacy to metoclopramide, 21% adverse event rate vs 50% for chlorpromazine) 1

Critical Frequency Limitation to Prevent Medication-Overuse Headache

• Strictly limit ALL acute migraine medications to no more than 2 days per week (10 days per month maximum) 1, 2, 3

  • Medication-overuse headache develops with NSAIDs used ≥15 days/month or triptans used ≥10 days/month 1
  • This creates a vicious cycle of increasing headache frequency leading to daily headaches 1

• If requiring acute treatment more than twice weekly, initiate preventive therapy immediately 1, 3

Preventive Therapy Indications

Preventive therapy is indicated when patients experience: 1, 3

• ≥2 attacks per month producing disability lasting ≥3 days
• Use of acute medications more than twice weekly
• Contraindication to or failure of acute treatments
• Uncommon migraine variants (hemiplegic migraine, prolonged aura)

First-Line Preventive Medications

• Beta-blockers: Propranolol 80-240 mg/day or timolol 20-30 mg/day 1, 3
• Topiramate: Effective for both episodic and chronic migraine, but discuss teratogenic effects with patients of childbearing potential 2, 3
• Amitriptyline: 30-150 mg/day, particularly useful for mixed migraine and tension-type headache 1, 3
• CGRP monoclonal antibodies: Consider when oral preventives fail or are contraindicated (assess efficacy after 3-6 months) 1
• OnabotulinumtoxinA: 155 units for chronic migraine (≥15 headache days/month), FDA-approved with strong evidence 3

Non-Pharmacologic Treatments

• Aerobic exercise: 40 minutes of moderate-to-intense aerobic exercise three times weekly is as effective as topiramate or relaxation therapy 3
• Behavioral interventions: Cognitive-behavioral therapy, biofeedback, and relaxation training have good evidence and should be integrated into comprehensive management 3
• Lifestyle modifications: Regular meals, adequate hydration, sufficient sleep, stress management with mindfulness practices 2, 3

Medications to Absolutely Avoid

• Opioids (including hydromorphone): Questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time 1, 4

  • Reserve only for cases where all other medications cannot be used, sedation is not a concern, and abuse risk has been addressed 1

• Butalbital-containing compounds: Associated with medication-overuse headache and dependency 1, 4

Common Pitfalls to Avoid

• Taking medication too late in the attack: Triptans and NSAIDs are most effective when taken early while headache is still mild 1, 2
• Using monotherapy when combination therapy is superior: Triptan plus NSAID is more effective than either alone for moderate-to-severe attacks 1, 2
• Not recognizing medication-overuse headache: Assess frequency of acute medication use at every visit 1
• Failing to initiate preventive therapy: When patients need acute treatment more than twice weekly, preventive therapy should be started immediately 1, 3
• Giving up after one triptan fails: Failure of one triptan does not predict failure of others; try at least 2-3 different triptans before declaring triptan failure 1

Contraindications Requiring Alternative Approach

• Triptans are contraindicated in: Ischemic vascular disease, vasospastic coronary disease, uncontrolled hypertension, significant cardiovascular disease 1
• Ketorolac should be used with caution in: Renal impairment (creatinine clearance <30 mL/min), history of GI bleeding, aspirin/NSAID-induced asthma 1
• Metoclopramide/prochlorperazine contraindicated in: Pheochromocytoma, seizure disorder, GI bleeding, GI obstruction, CNS depression 1