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)

• NSAIDs are the cornerstone of first-line therapy, with ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg taken at migraine onset while pain is still mild 1, 2
• The aspirin-acetaminophen-caffeine combination (250 mg/250 mg/65 mg, typically 2 tablets) is highly effective with a number needed to treat of 4 for pain relief at 2 hours 2
• Limit NSAID use to no more than 2 days per week to prevent medication-overuse headache 1, 2

Moderate-to-Severe Attacks (Escalation Strategy)

• Combination therapy with triptan plus NSAID is superior to either agent alone and represents the strongest evidence-based approach 1, 2
• Oral triptans with robust evidence include sumatriptan 50-100 mg, rizatriptan 10 mg, naratriptan 2.5 mg, and zolmitriptan 2.5-5 mg 1
• The combination of sumatriptan 50-100 mg plus naproxen sodium 500 mg provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to monotherapy 1
• Take medication early in the attack while headache is still mild for maximum effectiveness 1, 2

When Triptans Fail or Are Contraindicated

• CGRP antagonists (gepants) are the primary alternative: ubrogepant 50-100 mg or rimegepant 75 mg have no vasoconstriction and are safe for patients with cardiovascular disease, uncontrolled hypertension, or cerebrovascular disease 1, 2
• Lasmiditan 50-200 mg (5-HT1F agonist) is a second-line alternative without vasoconstrictor activity, but patients must not drive for at least 8 hours due to CNS effects 1, 2
• If one triptan fails, try a different triptan before abandoning the class entirely, as failure of one does not predict failure of others 1

Route Selection Based on Symptoms

• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% pain-free at 2 hours) with onset within 15 minutes, ideal for rapid progression to peak intensity or significant vomiting 1
• Intranasal sumatriptan 5-20 mg or nasal spray triptans are appropriate when significant nausea or vomiting is present 1
• Non-oral routes are preferred when significant nausea or vomiting occurs early in the attack 1, 2

Managing Associated Nausea

• Metoclopramide 10 mg provides direct analgesic effects through central dopamine receptor antagonism beyond its antiemetic properties, and should not be restricted only to patients who are vomiting 1
• Prochlorperazine 10 mg (oral or IV) is equally effective to metoclopramide with a more favorable side effect profile 1
• Add antiemetics 20-30 minutes before NSAIDs or triptans for synergistic analgesia 1

Emergency Department/Urgent Care IV Treatment

The optimal IV cocktail combines metoclopramide 10 mg IV plus ketorolac 30 mg IV for rapid pain relief with minimal rebound headache risk. 1

• Metoclopramide 10 mg IV provides independent analgesic benefit through central dopamine receptor antagonism 1
• Ketorolac 30 mg IV (60 mg IM for patients <65 years) has rapid onset and approximately 6 hours duration 1
• Prochlorperazine 10 mg IV is an alternative to metoclopramide with comparable efficacy 1
• Dihydroergotamine (DHE) IV or intranasal has good evidence as monotherapy for refractory cases 1

Critical Frequency Limitation

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, 3

• Medication-overuse headache creates a vicious cycle of increasing headache frequency leading to daily headaches 1
• If patients require acute treatment more than twice weekly, initiate preventive therapy immediately rather than allowing increased frequency of acute medication use 1, 3

Preventive Therapy Indications

Initiate preventive therapy when patients experience: 1, 2, 3

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

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, 3
• Topiramate 50-200 mg/day is the only oral medication proven effective specifically for chronic migraine (≥15 headache days/month), but requires discussion of teratogenic effects with patients of childbearing potential 2, 3
• Amitriptyline 30-150 mg/day is particularly effective for patients with mixed migraine and tension-type headache 1, 3
• OnabotulinumtoxinA 155 units is FDA-approved specifically for chronic migraine based on large-scale placebo-controlled trials 3

Preventive Therapy Timeline

• Oral preventive medications require 2-3 months for efficacy assessment 1
• CGRP monoclonal antibodies require 3-6 months for efficacy assessment 1
• OnabotulinumtoxinA requires 6-9 months for efficacy assessment 1

Non-Pharmacologic Treatments

• Regular moderate-to-intense aerobic exercise for 40 minutes three times weekly is as effective as topiramate or relaxation therapy for migraine prevention 3
• Cognitive-behavioral therapy, biofeedback, and relaxation training have good evidence for efficacy and should be integrated into comprehensive management 2, 3
• Maintain regular meals, stay well hydrated, ensure sufficient sleep, and manage stress with relaxation techniques or mindfulness practices 2

Medications to Absolutely Avoid

Never use opioids or butalbital-containing compounds for acute migraine treatment, as they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time. 1, 2

Common Pitfalls to Avoid

• Do not delay triptan administration—triptans are most effective when taken early while headache is still mild 1, 2
• Do not use monotherapy when combination therapy (triptan plus NSAID) is indicated for moderate-to-severe attacks 1, 2
• Do not allow patients to increase frequency of acute medication use in response to treatment failure—transition to preventive therapy instead 1
• Do not assume all triptans will fail if one triptan is ineffective—try different triptans before abandoning the class 1
• Do not restrict metoclopramide only to patients who are vomiting—nausea itself is one of the most disabling symptoms and warrants treatment 1