What is the recommended treatment for a patient with migraines?

Recommended Treatment for Migraine

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; for moderate to severe attacks or when NSAIDs fail, use triptans (sumatriptan 50-100 mg, rizatriptan 10 mg, or alternatives) combined with an NSAID for superior efficacy. 1

Acute Treatment Algorithm

First-Line Treatment Selection

Mild to Moderate Attacks:

• Begin with NSAIDs: ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg 1, 2
• Add acetaminophen 1000 mg if NSAIDs alone are insufficient 1
• Consider combination therapy with aspirin + acetaminophen + caffeine for enhanced absorption and synergistic analgesia 1

Moderate to Severe Attacks:

• Use triptan + NSAID combination therapy immediately, as this provides superior efficacy compared to either agent alone 1
• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg achieves sustained pain relief in 130 more patients per 1000 at 48 hours compared to monotherapy 1
• Alternative triptans include rizatriptan 10 mg (fastest oral triptan, peak at 60-90 minutes), eletriptan 40 mg, or zolmitriptan 2.5-5 mg 1, 2

Route of Administration Based on Symptoms

Significant Nausea/Vomiting Present:

• Use subcutaneous sumatriptan 6 mg for highest efficacy (59% complete pain relief at 2 hours, onset within 15 minutes) 1, 3
• Alternative: intranasal sumatriptan 5-20 mg or intranasal zolmitriptan 1

Oral Route Tolerated:

• Standard oral triptans as above 3
• Take medication early in the attack while pain is still mild for maximum effectiveness 1, 4

Adjunctive Antiemetic Therapy

• Add metoclopramide 10 mg or prochlorperazine 25 mg orally 20-30 minutes before the triptan/NSAID for synergistic analgesia beyond antiemetic effects 1
• Metoclopramide provides direct analgesic benefit through central dopamine receptor antagonism, not just nausea control 1

Second-Line and Rescue Treatment

If Initial Treatment Fails After 2-3 Attacks:

• Try a different triptan, as failure of one does not predict failure of others 1, 4
• Consider naratriptan (longest half-life, may decrease recurrence) or eletriptan/zolmitriptan (reportedly more effective than sumatriptan) 1

For Refractory Attacks:

• Intranasal or IV dihydroergotamine (DHE) has good evidence for efficacy as monotherapy 1, 2
• IV metoclopramide 10 mg + IV ketorolac 30 mg provides rapid relief for severe attacks requiring emergency treatment 1

Contraindications to Triptans (cardiovascular disease, uncontrolled hypertension):

• Use gepants: ubrogepant 50-100 mg or rimegepant (no vasoconstriction) 1
• Alternative: lasmiditan 50-200 mg (5-HT1F agonist without vasoconstrictor activity), but patients cannot drive for 8 hours after use 1

Critical Frequency Limitation

Limit all acute migraine medications to no more than 2 days per week (maximum 10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 5, 4

When to Initiate Preventive Therapy

Start preventive therapy immediately if:

• Patient experiences ≥2 migraine attacks per month producing disability for ≥3 days 6
• Patient uses acute medications more than twice weekly 6
• Acute treatments are contraindicated or consistently fail 6

First-line preventive options:

• Propranolol 80-240 mg/day or timolol 20-30 mg/day 6
• Topiramate 50-100 mg/day (particularly for patients with obesity due to weight loss benefit) 6
• Candesartan (especially with comorbid hypertension) 6

Second-line preventive options:

• Amitriptyline 30-150 mg/day (particularly for mixed migraine/tension-type headache or comorbid depression) 6
• Flunarizine 5-10 mg once daily at night (effective second-line agent where available) 6, 7

Medications to Absolutely Avoid

Never use opioids or butalbital-containing compounds as routine migraine treatment, as they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time. 1, 5, 4

Reserve opioids only for cases where all other evidence-based treatments are contraindicated, sedation is not a concern, and abuse risk has been addressed 1

Common Pitfalls to Avoid

• Do not wait until pain is severe to treat—early treatment while pain is mild improves efficacy 1, 4
• Do not abandon triptan therapy after one failed attempt—try different triptans or routes before declaring failure 1
• 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 use preventive medications (like valproate) in women of childbearing potential without addressing teratogenic risk 6