What are the treatment options for a patient experiencing migraine headaches?

Migraine Headache Treatment

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) or the combination of aspirin-acetaminophen-caffeine; for moderate to severe attacks, use a triptan (sumatriptan 50-100 mg, rizatriptan 10 mg, or others) combined with an NSAID, taken as early as possible when pain is still mild. 1, 2

First-Line Acute Treatment Algorithm

For Mild to Moderate Attacks:

• NSAIDs are the primary first-line option with proven efficacy and favorable tolerability 1, 2
• Ibuprofen 400-800 mg every 6 hours is the most effective over-the-counter option 3
• Naproxen sodium 500-825 mg provides longer duration of action (can repeat every 2-6 hours) 1, 3
• Aspirin 650-1000 mg every 4-6 hours has proven efficacy 3
• The aspirin-acetaminophen-caffeine combination is strongly recommended with a number needed to treat of 9 for pain freedom at 2 hours 2
• Never use acetaminophen alone—it is ineffective for migraine 4, 3

For Moderate to Severe Attacks:

• Triptans are first-line therapy and should be combined with an NSAID for superior efficacy 1, 2
• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg provides the strongest evidence, with 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 1
• Rizatriptan 10 mg reaches peak concentration fastest (60-90 minutes) among oral triptans 1, 3
• Take medication early when pain is still mild—this is critical for maximum effectiveness 1, 2, 5

Route Selection Based on Symptoms

When Nausea or Vomiting is Present:

• Use non-oral routes of administration 4, 1, 2
• Subcutaneous sumatriptan 6 mg provides highest efficacy (59% complete pain relief by 2 hours) with onset within 15 minutes 1, 5
• Intranasal sumatriptan 5-20 mg is an alternative non-oral option 1
• Add metoclopramide 10 mg IV or prochlorperazine 10 mg IV for both antiemetic effect and direct analgesic benefit 4, 1

For Severe Attacks Requiring IV Treatment:

• Metoclopramide 10 mg IV PLUS ketorolac 30 mg IV is the recommended first-line IV combination 1
• Ketorolac has rapid onset with approximately 6 hours duration and minimal rebound headache risk 4, 1
• Prochlorperazine 10 mg IV effectively relieves headache pain and is comparable to metoclopramide 4, 1

When First-Line Treatment Fails

If One Triptan Fails:

• Try a different triptan—failure of one does not predict failure of others 1, 3
• Trial each triptan for 2-3 headache episodes before abandoning it 1, 3
• Eletriptan 40 mg or zolmitriptan 2.5-5 mg may be more effective with fewer adverse reactions than sumatriptan 1
• Consider changing route: subcutaneous sumatriptan 6 mg provides 70-82% response versus only 50-67% for oral formulations 1

Alternative Agents When Triptans Fail or Are Contraindicated:

• CGRP antagonists (gepants) are the primary alternative: ubrogepant 50-100 mg or rimegepant 1, 2
• These have no vasoconstriction, making them safe for patients with cardiovascular disease, uncontrolled hypertension, or cerebrovascular disease 1
• Lasmiditan 50-200 mg (a 5-HT1F agonist) is second-line when gepants are unavailable, but patients cannot drive for 8 hours after taking it 1
• Dihydroergotamine (DHE) intranasal or IV has good evidence for efficacy as monotherapy 4, 1

Critical Medication Frequency Limits

Limit ALL acute migraine medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache. 1, 2, 5

• Medication overuse headache presents as daily headaches or marked increase in migraine frequency 1, 5
• NSAIDs trigger medication overuse at ≥15 days/month; triptans at ≥10 days/month 1
• If requiring acute treatment more than twice weekly, initiate preventive therapy immediately 1, 3

Medications to Absolutely Avoid

• Never use opioids (hydromorphone, meperidine, oxycodone) or butalbital-containing compounds as they lead to dependency, rebound headaches, and loss of efficacy 4, 1, 2, 6
• Opioids should only be reserved for when all other medications cannot be used, sedation is not a concern, and abuse risk has been addressed 1

Contraindications to Triptans (Use Alternatives)

Triptans are contraindicated in: 5

• Ischemic heart disease or previous myocardial infarction
• Prinzmetal's variant angina or coronary artery vasospasm
• Wolff-Parkinson-White syndrome or cardiac accessory pathway disorders
• History of stroke or transient ischemic attack
• Uncontrolled hypertension
• Hemiplegic or basilar migraine

When to Initiate Preventive Therapy

Start preventive therapy when: 1, 2, 7

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

First-Line Preventive Medications:

• Propranolol 80-240 mg/day has the strongest evidence 1, 3, 7
• Topiramate 100 mg/day is highly effective but requires discussion of teratogenic effects with women of childbearing potential 3, 2
• Amitriptyline 30-150 mg/day for patients with mixed migraine and tension-type headache 1
• Avoid valproate in women of childbearing age due to teratogenic effects 1, 3
• Start preventive medications at low dose and titrate slowly over 2-3 months to assess efficacy 3, 2

Common Pitfalls to Avoid

• Taking medication too late in the attack—triptans lose effectiveness if not taken when pain is still mild 1, 2, 5
• Using acetaminophen alone—it has no efficacy for migraine as monotherapy 4, 3
• Not combining triptan with NSAID—combination therapy is superior to either agent alone 1, 2
• Allowing patients to increase acute medication frequency—this creates medication-overuse headache; transition to preventive therapy instead 1
• Prescribing opioids or butalbital compounds—these worsen long-term outcomes and should be avoided 4, 1, 2, 6