What are the recommended treatment options for a patient experiencing migraines?

Migraine Treatment

Acute Treatment Strategy

For mild to moderate migraine attacks, start with NSAIDs (aspirin, ibuprofen, or naproxen sodium) as first-line therapy, taken as early as possible while pain is still mild. 1

First-Line Acute Options

• NSAIDs are the initial treatment of choice for mild to moderate attacks, with strongest evidence supporting aspirin, ibuprofen, naproxen sodium, and tolfenamic acid 1
• The aspirin-acetaminophen-caffeine combination provides superior efficacy with a number needed to treat of 9 for pain freedom at 2 hours and 4 for pain relief at 2 hours 1
• Acetaminophen alone is ineffective and should not be used as monotherapy for migraine treatment 1
• Timing is critical: take medication as early as possible during the attack while pain is still mild to maximize effectiveness 1

When to Escalate to Triptans

• Use triptans when NSAIDs provide inadequate relief or for moderate to severe attacks 1
• Combining a triptan with an NSAID provides superior efficacy compared to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1
• Oral triptans (rizatriptan, zolmitriptan) have good evidence for efficacy, with rizatriptan showing 33% of patients achieving pain freedom at 2 hours 2

Critical Acute Treatment Pitfalls

• Limit simple analgesics to fewer than 15 days/month and triptans to fewer than 10 days/month to prevent medication overuse headache 3, 4
• Avoid oral ergot alkaloids, opioids, and barbiturates due to questionable efficacy with considerable adverse effects and dependency risk 3
• Triptans are contraindicated in patients with ischemic or vasospastic coronary artery disease, history of stroke or TIA, and uncontrolled hypertension 2, 4

Preventive Therapy Indications

Initiate preventive therapy for patients with two or more migraine attacks per month producing disability lasting 3 or more days, use of acute medication more than twice per week, contraindication to or failure of acute treatments, or presence of uncommon migraine conditions. 1

First-Line Preventive Medications

• Beta-blockers without intrinsic sympathomimetic activity (propranolol, metoprolol, atenolol, bisoprolol) have consistent evidence of efficacy, particularly useful in patients with comorbid hypertension 1, 3
• Topiramate (50-100 mg daily) is effective first-line prevention, especially beneficial in obese patients 1, 3
• Divalproex sodium/sodium valproate is effective first-line prevention, but discuss teratogenic effects with patients of childbearing potential and avoid in women who may become pregnant 1

Second-Line Options

• Amitriptyline or nortriptyline (10-100 mg at night) are particularly useful for patients with coexisting anxiety or depression 3
• Candesartan (angiotensin receptor blocker) is effective, particularly in hypertensive patients 1, 3

Third-Line for Refractory Cases

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) should be considered when oral preventives have failed or are contraindicated, with efficacy assessed after 3-6 months 1, 3

Treatment Duration and Assessment

• Assess efficacy of oral preventive medications after 2-3 months at therapeutic dose 3
• Consider pausing treatment after 6-12 months of successful control to determine if preventive therapy can be stopped 3
• Failure of one preventive treatment does not predict failure of other drug classes 3

Non-Pharmacological Approaches

Regular moderate to intense aerobic exercise is as effective as some preventive medications for migraine prevention and should be incorporated into every treatment plan. 1

Essential Lifestyle Modifications

• Maintain adequate hydration and eat regular meals without skipping to help prevent migraines 1
• Ensure sufficient and consistent sleep (7-9 hours nightly) to help prevent migraines 1
• Practice stress management with relaxation techniques or mindfulness to help prevent migraines 1
• Identify and avoid individual migraine triggers through use of headache diaries 3

Dietary Supplements with Evidence

• Magnesium, riboflavin (vitamin B2), and coenzyme Q10 have supporting evidence for migraine prevention 5
• These supplements offer effective first-line treatments with minimal adverse effects 6

Special Considerations

Cardiovascular Risk Assessment for Triptans

• Triptan-naive patients with multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD) should have cardiovascular evaluation prior to receiving triptans 2, 4
• For high-risk patients with negative cardiovascular evaluation, consider administering the first triptan dose in a medically-supervised setting with ECG monitoring 2, 4

Comorbidity Management

• Identify and manage modifiable risk factors including obesity, medication overuse, caffeine use, obstructive sleep apnea, psychiatric comorbidities (anxiety, depression), and stress 3
• Choose preventive medications that address comorbid conditions (e.g., beta-blockers for hypertension, tricyclic antidepressants for depression) 1, 3