What are the recommended oral medications for a patient experiencing migraines?

Oral Medications for Acute Migraine Treatment

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) or acetaminophen 1000 mg as first-line therapy; for moderate to severe attacks, use a triptan (sumatriptan 50-100 mg, rizatriptan 10 mg, or eletriptan 40 mg) combined with an NSAID, which provides superior efficacy compared to either agent alone. 1, 2

First-Line Treatment Algorithm

For Mild to Moderate Attacks:

• NSAIDs are the initial choice, with ibuprofen 400-800 mg providing 2-hour headache relief in 57% of patients (versus 25% with placebo, NNT 3.2) 1, 3
• Naproxen sodium 500-825 mg is equally effective, with the advantage of longer duration of action 1, 4
• Aspirin 1000 mg or acetaminophen 1000 mg are alternatives when NSAIDs are contraindicated 1, 2
• Take medication early in the attack while pain is still mild to maximize effectiveness 1, 2

For Moderate to Severe Attacks:

• Combination therapy with triptan + NSAID is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1, 2
• Sumatriptan 50-100 mg plus naproxen sodium 500 mg is the most studied combination with high-certainty evidence 1
• Alternative triptans include rizatriptan 10 mg (reaches peak concentration in 60-90 minutes, fastest oral triptan), eletriptan 40 mg, or zolmitriptan 2.5-5 mg 5, 1
• If one triptan fails after 2-3 headache episodes, try a different triptan before abandoning this class, as failure of one does not predict failure of others 5, 1

Second-Line and Adjunctive Options

When Triptans Are Contraindicated:

• CGRP antagonists (gepants) are the preferred alternative for patients with cardiovascular disease, uncontrolled hypertension, or cerebrovascular disease 1, 2
• Ubrogepant 50-100 mg or rimegepant have no vasoconstrictor activity, making them safe when triptans cannot be used 1

For Severe Nausea or Vomiting:

• Add metoclopramide 10 mg orally, which provides direct analgesic effects through central dopamine receptor antagonism beyond its antiemetic properties 1, 2
• Prochlorperazine 25 mg orally is an alternative antiemetic with comparable efficacy 1
• Consider non-oral routes (intranasal or subcutaneous sumatriptan) when significant nausea prevents oral absorption 5, 1

Critical Frequency Limitation

Strictly limit all acute migraine medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 2 The threshold varies by medication class: ≥15 days per month with NSAIDs triggers medication-overuse headache, while ≥10 days per month with triptans does the same. 1, 2

When to Initiate Preventive Therapy

If you require acute treatment more than twice weekly, or experience ≥2 migraine attacks per month with disability lasting ≥3 days, preventive therapy is indicated immediately. 1, 6, 2 First-line preventive options include:

• Propranolol 80-240 mg/day (FDA-approved, strong evidence) 6, 7
• Topiramate 100 mg/day (typically 50 mg twice daily) 6
• Candesartan (particularly useful with comorbid hypertension) 6

Allow 2-3 months for oral preventive agents to demonstrate efficacy. 6

Medications to Absolutely Avoid

Do not 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 These should only be reserved for when other medications cannot be used, sedation is not a concern, and abuse risk has been addressed. 1

Special Populations

Pregnancy:

• Acetaminophen 1000 mg is the safest option during pregnancy 8
• Sumatriptan may be considered for selected patients (Pregnancy Category C), though embryolethality and fetal abnormalities occurred in animal studies 9, 8
• Avoid breastfeeding for 12 hours after sumatriptan use to minimize infant exposure 9

Hepatic Impairment:

• Maximum single dose of sumatriptan should not exceed 50 mg in mild to moderate hepatic impairment; sumatriptan is contraindicated in severe hepatic impairment 9

Common Pitfalls to Avoid

• Using subtherapeutic doses: Ensure adequate dosing (ibuprofen 400-800 mg, not 200 mg; naproxen 500-825 mg; sumatriptan 50-100 mg, not 25 mg) before declaring treatment failure 1, 2
• Delaying medication administration: Taking medication early while pain is mild significantly improves efficacy 1, 2
• Abandoning triptans after single failure: Try 2-3 different triptans before concluding the class is ineffective 5, 1
• Allowing escalation of acute medication frequency: This creates medication-overuse headache; transition to preventive therapy instead 1, 2