What are the treatment options for a patient experiencing migraines?

How to Treat Migraine

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

First-Line Treatment Algorithm

Mild to Moderate Attacks

• Ibuprofen 400-800 mg every 6 hours is the most effective over-the-counter option, with 52-57% of patients achieving headache relief at 2 hours compared to 26% with placebo 1, 2, 3
• Naproxen sodium 500-825 mg provides longer duration of action and can be repeated every 2-6 hours, with a maximum of 1.5 g per day 1, 2
• Aspirin-acetaminophen-caffeine combination has strong evidence with a number needed to treat of 9 for pain freedom at 2 hours 1, 4, 2
• Never use acetaminophen alone—it has minimal efficacy for migraine as monotherapy 2, 5

Moderate to Severe Attacks

• Sumatriptan 50-100 mg combined with an NSAID is superior to either agent alone, with 61-62% achieving headache response at 2 hours versus 27% with placebo 1, 2, 6
• Alternative oral triptans include rizatriptan 10 mg (fastest oral triptan, reaching peak concentration in 60-90 minutes), eletriptan 40 mg, or zolmitriptan 2.5-5 mg 1
• If one triptan fails after 2-3 headache episodes, try a different triptan—failure of one does not predict failure of others 1, 4

Route Selection Based on Symptoms

When Nausea or Vomiting is Present

• Subcutaneous sumatriptan 6 mg provides the highest efficacy with 59% achieving complete pain relief by 2 hours, with onset within 15 minutes 1, 2, 6
• Intranasal sumatriptan 5-20 mg is an alternative non-oral option 1, 4
• Add metoclopramide 10 mg IV or prochlorperazine 10 mg IV for both antiemetic effect and direct analgesic benefit through central dopamine receptor antagonism 1, 2

IV Treatment for Severe Attacks

• Metoclopramide 10 mg IV plus ketorolac 30 mg IV is the recommended first-line combination for severe migraine requiring intravenous treatment 1
• Dihydroergotamine (DHE) intranasal or IV has good evidence for efficacy as monotherapy 1, 4

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, 4, 2

• NSAIDs trigger medication overuse at ≥15 days/month; triptans at ≥10 days/month 1, 2
• If requiring acute treatment more than twice weekly, initiate preventive therapy immediately 1, 2
• Medication overuse headache presents as daily headaches or marked increase in migraine frequency 1

Alternative Options When Triptans Fail or Are Contraindicated

CGRP Antagonists (Gepants)

• Ubrogepant 50-100 mg or rimegepant are recommended as primary alternatives when triptans are contraindicated, with no vasoconstriction making them safe for patients with cardiovascular disease 1, 4
• Number needed to treat is 13 for pain freedom at 2 hours 4

Lasmiditan (Ditan)

• Lasmiditan 50-200 mg is a 5-HT1F receptor agonist without vasoconstrictor activity 1, 4
• Patients must not drive or operate machinery for at least 8 hours after taking lasmiditan due to CNS effects (dizziness, vertigo, somnolence) 1

Absolute Contraindications to Triptans

Triptans are contraindicated in patients with: 1, 2

• 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

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 over time. 1, 4, 2, 5, 7

When to Initiate Preventive Therapy

Start preventive therapy when: 1, 4, 2

• Using acute medications more than twice per week
• Two or more attacks per month producing disability lasting 3+ days
• Contraindication to or failure of acute treatments

First-Line Preventive Medications

• Propranolol 80-240 mg/day has the strongest evidence 1, 2
• Topiramate 100 mg/day is highly effective but requires discussion of teratogenic effects with women of childbearing potential 1, 4, 2
• Amitriptyline 30-150 mg/day for patients with mixed migraine and tension-type headache 1, 2
• OnabotulinumtoxinA 155 units for chronic migraine (≥15 headache days per month) 4

Common Pitfalls to Avoid

• Taking medication too late in the attack—triptans lose effectiveness if not taken when pain is still mild 1, 4, 2
• Not combining triptan with NSAID—combination therapy is superior to either agent alone 1, 4, 2
• Allowing patients to increase acute medication frequency—this creates medication-overuse headache; transition to preventive therapy instead 1, 2
• Using acetaminophen alone—it has no efficacy for migraine as monotherapy 2, 5

Lifestyle Modifications

• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 4
• Engage in regular moderate to intense aerobic exercise (40 minutes three times weekly), which is as effective as some preventive medications 4
• Manage stress with relaxation techniques or mindfulness practices 4
• Use a headache diary to identify triggers and monitor medication use 4