What are the treatment options for a patient with recurrent migraine headaches?

Treating Migraine Headaches

For acute migraine treatment, start with combination therapy of a triptan plus NSAID (sumatriptan 50-100 mg + naproxen 500 mg) for moderate to severe attacks, or NSAIDs alone for mild to moderate attacks, taken as early as possible when pain is still mild. 1, 2

Acute Treatment Algorithm

Mild to Moderate Migraine (First-Line)

• NSAIDs are the initial choice, with specific evidence supporting ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg taken at headache onset. 1, 2
• Aspirin-acetaminophen-caffeine combination (e.g., Excedrin Migraine) is highly effective with a number needed to treat of 4 for pain relief at 2 hours. 2
• Acetaminophen 1000 mg has less efficacy than NSAIDs and should only be used when NSAIDs are contraindicated. 2

Moderate to Severe Migraine (First-Line)

• Combination therapy with triptan + NSAID is superior to either agent alone, providing 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to monotherapy. 1
• Sumatriptan 50-100 mg plus naproxen sodium 500 mg is the evidence-based combination with the strongest recommendation. 1, 2
• Alternative oral triptans include rizatriptan 10 mg (fastest oral triptan, reaching peak in 60-90 minutes), eletriptan 40 mg, or zolmitriptan 2.5-5 mg. 1, 3
• Timing is critical: triptans work best when taken early while headache is still mild, not after pain becomes severe. 1, 2

Severe Migraine with Nausea/Vomiting

• Subcutaneous sumatriptan 6 mg provides the highest efficacy with 70-82% achieving pain relief within 15 minutes and 59% achieving complete pain freedom by 2 hours. 1, 4
• Intranasal sumatriptan 5-20 mg or other nasal spray triptans are alternatives when oral route is compromised. 1
• Add metoclopramide 10 mg IV or prochlorperazine 10 mg IV for both antiemetic effect and synergistic analgesia. 1

IV Treatment for Emergency/Urgent Care Settings

• First-line IV cocktail: metoclopramide 10 mg IV + ketorolac 30 mg IV provides rapid relief with minimal rebound headache risk. 1
• Prochlorperazine 10 mg IV is equally effective to metoclopramide with comparable efficacy. 1
• Dihydroergotamine (DHE) IV or intranasal is an alternative with good evidence for efficacy as monotherapy. 1

Critical Frequency Limitation

Strictly limit ALL acute migraine medications to no more than 2 days per week (10 days per month for triptans, 15 days per month for NSAIDs) to prevent medication-overuse headache. 1, 2 Exceeding this threshold creates a vicious cycle where headaches become daily and medications lose effectiveness. 1

When First-Line Treatment Fails

Try Alternative Triptans First

• Failure of one triptan does not predict failure of others—try at least 2-3 different triptans before abandoning this class. 1
• Eletriptan 40 mg and zolmitriptan 2.5-5 mg are reportedly more effective with fewer adverse effects than sumatriptan. 1
• Naratriptan has the longest half-life, potentially decreasing recurrence headaches. 1
• Consider changing the route: subcutaneous or intranasal formulations may work when oral fails. 1

Second-Line Options When All Triptans Fail

• CGRP antagonists (gepants) like ubrogepant 50-100 mg or rimegepant are the primary alternatives when triptans are contraindicated or ineffective, with no vasoconstriction making them safe for cardiovascular disease. 1
• Lasmiditan 50-200 mg (5-HT1F agonist) is another non-vasoconstrictor option, but requires an 8-hour driving restriction due to CNS effects. 1
• Dihydroergotamine (DHE) intranasal or IV has good evidence for efficacy. 1

Medications to Absolutely Avoid

• Never use opioids or butalbital-containing compounds for migraine treatment—they lead to dependency, rebound headaches, medication-overuse headache, and eventual loss of efficacy. 1, 2

Contraindications Requiring Alternative Approach

• Triptans are absolutely contraindicated in ischemic heart disease, uncontrolled hypertension, cerebrovascular disease, peripheral vascular disease, hemiplegic migraine, and basilar migraine. 1, 5
• For these patients, use gepants (ubrogepant/rimegepant), lasmiditan, or DHE as first-line alternatives. 1

Preventive Therapy Indications

Initiate preventive therapy immediately if: 1, 2

• Two or more attacks per month producing disability lasting 3+ days
• Using acute medications more than 2 days per week
• Contraindication to or failure of acute treatments
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura)

First-Line Preventive Options

• Beta-blockers: propranolol 80-240 mg/day or timolol 20-30 mg/day have the most consistent evidence. 1, 5
• Topiramate 25-100 mg/day is effective but requires discussion of teratogenic effects with women of childbearing potential. 2
• Amitriptyline 30-150 mg/day is particularly useful for mixed migraine and tension-type headache. 1, 5
• CGRP monoclonal antibodies should be considered when oral preventives fail, with efficacy assessed after 3-6 months. 1

Chronic Migraine (≥15 headache days/month)

• OnabotulinumtoxinA 155 units is FDA-approved specifically for chronic migraine based on large-scale trials, with efficacy assessed after 6-9 months. 1, 2

Lifestyle Modifications

• Maintain regular meals, adequate hydration, and consistent sleep schedule. 5, 2
• Engage in regular moderate to intense aerobic exercise 40 minutes three times weekly—this is as effective as some preventive medications. 2
• Manage stress with relaxation techniques or mindfulness practices. 5, 2
• Keep a headache diary to identify triggers and monitor medication use patterns. 2

Common Pitfalls to Avoid

• Do not wait until pain is severe to take medication—early treatment while pain is mild dramatically improves efficacy. 1, 2
• Do not allow patients to increase acute medication frequency in response to treatment failure—this creates medication-overuse headache. Instead, transition to preventive therapy. 1
• Do not assume all headaches are the same—most patients describe various intensities, with milder episodes often representing milder versions of migraine that may respond to NSAIDs alone. 6
• Do not use prednisone or corticosteroids for routine acute migraine—they have limited evidence and are more appropriate for status migrainosus. 1