What is the first line treatment for a patient experiencing migraines?

First-Line Treatment for Migraine

For mild to moderate migraine attacks, start with NSAIDs—specifically ibuprofen 400-800 mg, naproxen sodium 500-825 mg, aspirin 900-1000 mg, or diclofenac potassium—as these have the strongest evidence for first-line therapy. 1, 2, 3 For moderate to severe attacks, use a triptan (sumatriptan 50-100 mg, rizatriptan 10 mg, or eletriptan 40 mg) as first-line therapy, ideally taken early when pain is still mild. 1, 2, 3

Treatment Algorithm Based on Attack Severity

Mild to Moderate Attacks

• NSAIDs are the definitive first-line choice, with acetylsalicylic acid, ibuprofen, naproxen sodium, and diclofenac potassium having the strongest evidence. 1, 2
• Ibuprofen dosing: 400-800 mg every 6-8 hours as needed. 3, 4
• Naproxen sodium dosing: 500-825 mg at onset, can repeat every 2-6 hours (maximum 1.5 g/day). 2
• Aspirin dosing: 900-1000 mg at onset. 3, 5
• Acetaminophen 1000 mg has less efficacy than NSAIDs and should only be used in patients intolerant of NSAIDs. 1

Moderate to Severe Attacks

• Triptans are first-line therapy for moderate to severe migraine. 1, 2, 3
• Sumatriptan 50-100 mg orally is the most studied, with 50 mg and 100 mg providing greater effect than 25 mg (though 100 mg may not exceed 50 mg efficacy). 6, 5
• Rizatriptan 10 mg reaches peak concentration in 60-90 minutes, making it the fastest oral triptan. 2
• Alternative triptans include eletriptan 40 mg, zolmitriptan 2.5-5 mg, naratriptan, almotriptan, and frovatriptan. 2, 5, 7
• Triptans are most effective when taken early in the attack while headache is still mild, but should NOT be taken during the aura phase. 1, 3

Superior Combination Strategy

• The combination of triptan + NSAID (e.g., sumatriptan 50-100 mg + naproxen sodium 500 mg) is superior to either agent alone and represents the strongest recommendation from recent guidelines. 2
• This combination provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to monotherapy. 2

When Nausea/Vomiting is Prominent

• Select non-oral routes of administration when significant nausea or vomiting is present. 2, 3
• Subcutaneous sumatriptan 6 mg provides the highest efficacy with onset within 15 minutes, achieving pain relief in 70-82% of patients and complete relief in 59% by 2 hours. 2, 8
• Intranasal sumatriptan 5-20 mg or nasal spray triptans are alternatives. 2, 8
• Add an antiemetic: metoclopramide 10 mg IV/oral or prochlorperazine 10 mg IV provides both antiemetic effects and synergistic analgesia. 2, 7

Critical Frequency Limitation

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, 3 If patients require acute treatment more than twice weekly, immediately initiate preventive therapy rather than increasing acute medication frequency. 2

Rescue Dosing

• If migraine has not resolved by 2 hours after initial triptan dose, a second dose may be administered at least 2 hours after the first dose. 6
• Maximum daily triptan dose: 200 mg sumatriptan in 24 hours. 6
• If one triptan is ineffective after 2-3 headache episodes, try a different triptan, as failure of one does not predict failure of others. 1, 2

Important Contraindications

• Triptans are contraindicated in patients with ischemic heart disease, vasospastic coronary disease, uncontrolled hypertension, basilar or hemiplegic migraine, or significant cardiovascular disease. 2, 3, 5
• In patients with mild to moderate hepatic impairment, maximum single sumatriptan dose should not exceed 50 mg. 6

Medications to Avoid

• Opioids should NOT be used routinely for acute migraine treatment, as they lead to dependency, rebound headaches, and eventual loss of efficacy. 2, 5, 7
• Butalbital-containing compounds should be avoided for similar reasons. 2

When First-Line Therapy Fails

• Escalate to dihydroergotamine (DHE) 0.5-1 mg IM/IV or intranasal, which has good evidence for efficacy as monotherapy. 2, 5
• Consider newer CGRP antagonists (gepants: ubrogepant 50-100 mg or rimegepant) as alternatives when triptans are contraindicated or ineffective. 2
• Lasmiditan 50-200 mg (5-HT1F agonist) is another option without vasoconstrictor activity, though patients cannot drive for 8 hours after use. 2