What are the treatment options for a patient experiencing migraines?

Migraine Treatment

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) or aspirin-acetaminophen-caffeine combination; for moderate to severe attacks, 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

• 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 2
• Naproxen sodium 500-825 mg provides longer duration of action (repeat every 2-6 hours, maximum 1.5 g/day) 1, 2
• Aspirin 650-1000 mg every 4-6 hours has proven efficacy 2
• The aspirin-acetaminophen-caffeine combination is strongly recommended with a number needed to treat of 9 for pain freedom at 2 hours 3, 2
• Never use acetaminophen alone—it is ineffective for migraine as monotherapy 3, 2

Moderate to Severe Attacks

• Triptans combined with NSAIDs are superior to either agent alone and represent the strongest recommendation 1, 3, 2
• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to monotherapy 1
• Rizatriptan 10 mg reaches peak concentration in 60-90 minutes, making it the fastest oral triptan 1
• Eletriptan 40 mg or zolmitriptan 2.5-5 mg are more effective with fewer adverse reactions than sumatriptan 1
• Take medication as early as possible when pain is still mild—triptans lose effectiveness if taken late in the attack 1, 3, 2

Route Selection Based on Symptoms

When Nausea or Vomiting is Present

• Use non-oral routes of administration 1, 3, 2
• Subcutaneous sumatriptan 6 mg provides highest efficacy (59% complete pain relief by 2 hours) with onset within 15 minutes 1, 2
• Intranasal sumatriptan 5-20 mg is an alternative non-oral option 1, 2
• Add metoclopramide 10 mg IV or prochlorperazine 10 mg IV for both antiemetic effect and direct analgesic benefit 1, 2

IV Treatment for Severe Attacks

• Metoclopramide 10 mg IV PLUS ketorolac 30 mg IV is the recommended first-line IV combination therapy 1
• Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism beyond its antiemetic properties 1
• Ketorolac has rapid onset with approximately 6 hours duration and minimal rebound headache risk 1
• Prochlorperazine 10 mg IV is comparable to metoclopramide in efficacy 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, 3, 2

• NSAIDs trigger medication overuse at ≥15 days/month; triptans at ≥10 days/month 1, 2
• Medication overuse headache presents as daily headaches or marked increase in migraine frequency 1, 2
• If requiring acute treatment more than twice weekly, initiate preventive therapy immediately 1, 3, 2

Alternative Options When Triptans Fail or Are Contraindicated

Try Different Triptans First

• Failure of one triptan does not predict failure of others—try each medication for 2-3 headache episodes before abandoning that specific triptan 1
• Consider route change: subcutaneous or intranasal formulations may work when oral fails 1

CGRP Antagonists (Gepants)

• Ubrogepant 50-100 mg or rimegepant are the primary oral alternatives when triptans are contraindicated 1, 3
• Gepants have no vasoconstriction, making them safe for patients with cardiovascular disease, uncontrolled hypertension, or cerebrovascular disease 1
• Number needed to treat is 13 for pain freedom at 2 hours 3

Ditans (Lasmiditan)

• Lasmiditan 50-200 mg is a 5-HT1F receptor agonist without vasoconstrictor activity 1, 3
• Patients must not drive or operate machinery for at least 8 hours after taking lasmiditan due to CNS effects 1

Dihydroergotamine (DHE)

• Intranasal or IV DHE has good evidence for efficacy as monotherapy 1, 3

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. 1, 3, 2

When to Initiate Preventive Therapy

Start preventive therapy when: 1, 3, 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
• Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura)

First-Line Preventive Medications

• Propranolol 80-240 mg/day has the strongest evidence 1, 3, 2
• Topiramate 100 mg/day is highly effective but requires discussion of teratogenic effects with women of childbearing potential 1, 3, 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) 3
• Avoid valproate in women of childbearing age due to teratogenic effects 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, 3, 2
• Using acetaminophen alone—it has no efficacy for migraine as monotherapy 3, 2
• Not combining triptan with NSAID—combination therapy is superior to either agent alone 1, 3, 2
• Allowing patients to increase acute medication frequency—this creates medication-overuse headache; transition to preventive therapy instead 1, 2
• Prescribing opioids or butalbital compounds—these worsen long-term outcomes and should be avoided 1, 3, 2

Lifestyle Modifications

• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 3
• Engage in regular moderate to intense aerobic exercise (40 minutes three times weekly)—this is as effective as some preventive medications 3
• Manage stress with relaxation techniques or mindfulness practices 3
• Use a headache diary to identify triggers and monitor medication use 3