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

Migraine Management

Acute Treatment

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

First-Line Acute Treatment 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 pain freedom at 2 hours (NNT=9) and pain relief at 2 hours (NNT=4) 1
• Acetaminophen alone is ineffective and should not be used as monotherapy for migraine treatment 1
• Take medication as early as possible during the attack while pain is still mild to maximize effectiveness 1

Triptan Therapy

• Triptans should be used when NSAIDs provide inadequate relief or for moderate to severe attacks 1
• Oral sumatriptan (50-100 mg) provides headache response in 50-62% of patients at 2 hours and 68-79% at 4 hours, compared to 17-27% with placebo 2
• 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

Critical Medication Overuse Warning

• Limit simple analgesics to fewer than 15 days/month and triptans to fewer than 10 days/month to prevent medication overuse headache 1, 2
• Overuse of acute migraine drugs may lead to exacerbation of headache and marked increase in migraine frequency 2

Preventive Therapy

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

First-Line Preventive Medications

• Beta-blockers without intrinsic sympathomimetic activity (propranolol, metoprolol, atenolol, bisoprolol) have consistent evidence of efficacy, particularly beneficial in patients with comorbid hypertension 1
• Topiramate (50-100 mg daily) is effective first-line prevention, especially beneficial in obese patients 1
  • Common adverse effects include cognitive inefficiency, paresthesia, fatigue, and weight loss 1
  • Discuss teratogenic effects with patients of childbearing potential 1
• Divalproex sodium/sodium valproate is effective first-line prevention but has teratogenic effects requiring discussion with patients of childbearing potential 1
• Candesartan (angiotensin receptor blocker) is a first-line option, particularly useful in hypertensive patients 1

CGRP Monoclonal Antibodies

• CGRP monoclonal antibodies should be considered when oral preventives have failed or are contraindicated 1
• Assess efficacy after 3-6 months of treatment 1

Treatment Duration and Assessment

• Assess efficacy of oral preventive medications after 2-3 months at therapeutic dose 1
• Consider pausing treatment after 6-12 months of successful control to determine if preventive therapy can be stopped 1

Non-Pharmacological Approaches

Regular moderate to intense aerobic exercise is as effective as some preventive medications and should be recommended for all migraine patients. 1

Lifestyle Modifications (Essential for All Patients)

• Engage in regular moderate to intense aerobic exercise for migraine prevention 1
• 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

Additional Non-Pharmacological Options

• Biofeedback and cognitive-behavioral therapy have favorable efficacy profiles 3
• Dietary supplements including magnesium citrate, coenzyme Q10, and riboflavin (vitamin B2) have supporting evidence 3, 4

Critical Pitfalls to Avoid

• Never use opioids or barbiturates due to questionable efficacy, considerable adverse effects, and dependency risk 1
• Avoid oral ergot alkaloids due to questionable efficacy with considerable adverse effects 1
• Do not abandon preventive treatment prematurely, as efficacy takes weeks to months to establish 1
• Failure of one preventive treatment does not predict failure of other drug classes 1

Special Considerations for Triptans

• Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, history of stroke or TIA, and Wolff-Parkinson-White syndrome 2
• Perform cardiovascular evaluation in triptan-naive patients with multiple cardiovascular risk factors prior to prescribing 2
• Monitor for serotonin syndrome when co-administering with SSRIs, SNRIs, TCAs, or MAO inhibitors 2