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

Migraine Management

Acute Treatment Algorithm

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) as first-line therapy, and for moderate to severe attacks or when NSAIDs fail, use combination therapy with a triptan PLUS an NSAID, which provides superior efficacy compared to either agent alone. 1

First-Line Acute Treatment

• NSAIDs are the initial treatment of choice for mild to moderate migraine, with strongest evidence supporting aspirin, ibuprofen, naproxen sodium, and tolfenamic acid 1
• The aspirin-acetaminophen-caffeine combination has 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
• Take medication as early as possible during the attack while pain is still mild to maximize effectiveness 1

Escalation to Triptans

• Triptans should be used when NSAIDs provide inadequate relief or for moderate to severe attacks, with oral triptans having good evidence for efficacy 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
• Sumatriptan 50-100 mg achieves headache response (reduction to mild or no pain) in 52-62% of patients at 2 hours and 67-79% at 4 hours, compared to 17-27% and 19-38% with placebo 2
• Alternative oral triptans include rizatriptan 10 mg (fastest oral triptan, reaching peak concentration in 60-90 minutes), eletriptan 40 mg, zolmitriptan 2.5-5 mg, and naratriptan (longest half-life, may decrease recurrent headaches) 3

Route Selection Based on Severity

• For patients with rapid progression to peak intensity or significant nausea/vomiting, subcutaneous sumatriptan 6 mg provides the highest efficacy with 75% achieving pain relief within 15 minutes and 59% achieving complete pain relief by 2 hours 3, 2
• Intranasal sumatriptan (5-20 mg) or other nasal spray triptans are useful when significant nausea or vomiting is present 3

Intravenous Treatment for Severe Attacks

• The recommended IV cocktail consists of metoclopramide 10 mg IV PLUS ketorolac 30 mg IV for severe migraine attacks requiring intravenous treatment 3
• Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism, not just antiemetic properties 3
• Ketorolac has relatively rapid onset with approximately 6 hours duration and minimal risk of rebound headache 3
• Prochlorperazine 10 mg IV is an alternative to metoclopramide with comparable efficacy 3
• Dihydroergotamine (DHE) IV or intranasal has good evidence for efficacy as monotherapy 3

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 can paradoxically increase headache frequency and lead to daily headaches 1, 3, 2

Contraindications to Triptans

• Triptans are contraindicated in patients with ischemic heart disease, coronary artery vasospasm (Prinzmetal's angina), uncontrolled hypertension, history of stroke or TIA, Wolff-Parkinson-White syndrome, or other cardiac accessory conduction pathway disorders 2
• For patients with cardiovascular contraindications, consider gepants (ubrogepant 50-100 mg or rimegepant) as they have no vasoconstriction 3

Medications to Avoid

• Opioids should be reserved only for when other medications cannot be used, when sedation effects are not a concern, or when the risk for abuse has been addressed, as they lead to dependency, rebound headaches, and loss of efficacy 1, 3

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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, such as propranolol 80-240 mg/day or timolol 20-30 mg/day, have consistent evidence of efficacy 1, 4, 5
• Topiramate and divalproex sodium/sodium valproate are effective first-line options, but discuss teratogenic effects with patients of childbearing potential 1, 4
• Amitriptyline 30-150 mg/day is recommended for patients with mixed migraine and tension-type headache 3
• Candesartan has favorable efficacy and tolerability profile 4

CGRP Monoclonal Antibodies

• CGRP monoclonal antibodies should be considered when oral preventives have failed or are contraindicated, with efficacy assessed after 3-6 months 1, 4

Efficacy Timeline

• Oral preventive agents require 2-3 months to assess efficacy 3
• CGRP monoclonal antibodies require 3-6 months for efficacy assessment 1, 3
• OnabotulinumtoxinA (for chronic migraine only) requires 6-9 months 3

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Non-Pharmacological Approaches

• Engage in regular moderate to intense aerobic exercise, which is as effective as some preventive medications 1, 6
• Maintain adequate hydration and eat regular meals without skipping to help prevent migraines 1, 6
• Ensure sufficient and consistent sleep, 7-9 hours nightly 1, 6
• Practice stress management with relaxation techniques or mindfulness 1, 6
• Biofeedback and cognitive-behavioral therapy are effective first-line preventive options 1, 4

Nutraceuticals with Evidence

• Magnesium citrate, riboflavin (vitamin B2), and coenzyme Q10 have evidence supporting their use for migraine prevention 1, 4, 6

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Common Pitfalls to Avoid

• Do not allow patients to increase frequency of acute medication use in response to treatment failure, as this creates a vicious cycle of medication-overuse headache; instead transition to preventive therapy while optimizing acute treatment strategy 3
• Failure of one triptan does not predict failure of others—try a different triptan for 2-3 headache episodes before abandoning the class 3
• Do not use acetaminophen as monotherapy for migraine treatment, as it is ineffective 1
• Avoid establishing patterns of frequent opioid use, as this leads to dependency, rebound headaches, and eventual loss of efficacy 3
• Perform cardiovascular evaluation in triptan-naive patients with multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD) prior to prescribing triptans 2