Migraine Treatment
Use a stratified-care approach that assigns treatment based on migraine severity and disability level, starting with NSAIDs for mild-to-moderate attacks and triptans combined with NSAIDs for moderate-to-severe attacks, while initiating preventive therapy for patients with ≥2 disabling attacks per month or acute medication use >2 days per week. 1, 2
Acute Treatment Algorithm
For Mild-to-Moderate Migraine (Low Disability)
Start with NSAIDs as first-line therapy, taken as early as possible when pain is still mild: 2, 3
Add combination therapy if NSAIDs alone are insufficient: acetaminophen + aspirin + caffeine has high-quality evidence for efficacy 2
Administer prokinetic antiemetics for nausea/vomiting: domperidone or metoclopramide, considering nonoral routes when nausea is prominent 4
For Moderate-to-Severe Migraine (Moderate-to-High Disability)
Avoid triptans in specific contraindications: coronary artery disease, uncontrolled hypertension, hemiplegic migraine, basilar migraine 1, 4
Rescue Medications When First-Line Fails
Dihydroergotamine (DHE) for selected patients, though avoid chronic use due to peripheral vasoconstriction risk 1, 3
Opioids may be considered only as rescue when NSAIDs and triptans fail, but have questionable efficacy and dependency risk 4
Butalbital-containing compounds can serve as home rescue but carry medication overuse headache risk 4
Preventive Therapy Indications
Initiate preventive therapy immediately for: 2, 5
- ≥2 disabling migraine attacks per month 2
- Inadequate response to optimized acute treatment 2
- Acute medication use >2 days per week (to prevent medication overuse headache) 6, 2
- Special circumstances: hemiplegic migraine (regardless of frequency), status migrainosus 6, 4
First-Line Preventive Medications
Beta-blockers, tricyclic antidepressants (amitriptyline), and anticonvulsants (topiramate, divalproex 500-1500 mg/day) have documented high efficacy: 2, 5, 7
- Allow adequate trial period of 2-3 months before determining efficacy 4, 2
- After 6-12 months of successful treatment, consider tapering to assess ongoing need 4
Third-Line Preventive Options
CGRP monoclonal antibodies (erenumab) for patients failing first-line therapies, with efficacy assessed after 3-6 months 2, 8, 7
- Erenumab 70 mg or 140 mg subcutaneously once monthly reduces monthly migraine days by 1.4-1.9 days compared to placebo 8
- 43-50% of patients achieve ≥50% reduction in monthly migraine days 8
Special Populations
Hemiplegic Migraine
- NSAIDs are first-line; triptans and ergots are absolutely contraindicated due to prolonged vasospasm risk 4
- Hemiplegic migraine is an explicit indication for preventive therapy regardless of attack frequency 4
- Flunarizine 5-10 mg daily is particularly effective 4
Pregnancy
- Acetaminophen is the safest option; acetaminophen with codeine is also acceptable 3
- Sumatriptan may be considered for selected patients and is compatible with breastfeeding 3
- Avoid valproate/divalproex in women of childbearing potential 4
Critical Implementation Points
Track outcomes using headache diaries documenting attack frequency, severity, duration, disability, treatment response, and adverse effects 4, 2
Limit acute medication use to prevent medication overuse headache: 6, 4, 2
- NSAIDs: ≤10 days per month 4
- Triptans: ≤10 days per month 4
- Any acute medication: ≤2 days per week 6, 2
Evaluate treatment response 2-3 months after initiation, then every 6-12 months 2
Common Pitfalls to Avoid
- Never use step-care approach (starting with cheapest/safest then escalating); stratified-care based on disability is superior 1
- Never prescribe triptans for hemiplegic migraine even if patient requests based on prior use 4
- Never rely on acetaminophen monotherapy for acute migraine—it is ineffective 4
- Never declare preventive therapy failure before 2-3 months of adequate trial 4, 5
- Never ignore medication overuse headache risk in patients using acute medications frequently 6, 4