What are the treatment options for a patient with migraines?

Migraine Treatment

Acute Treatment Algorithm

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 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 Options for Mild to Moderate Migraine

• Ibuprofen 400-800 mg is the most effective over-the-counter option, providing headache relief in approximately 57% of patients at 2 hours versus 25% with placebo (NNT 3.2) 1, 3
• Naproxen sodium 500-825 mg provides longer duration of action and can be repeated every 2-6 hours, with maximum 1.5 g per day 1, 2
• Aspirin-acetaminophen-caffeine combination has strong evidence with NNT of 9 for pain freedom at 2 hours and NNT of 4 for pain relief at 2 hours 4, 2
• Never use acetaminophen alone—it has minimal efficacy for migraine as monotherapy and should only be used in patients intolerant of NSAIDs 4, 2

First-Line Options for Moderate to Severe Migraine

• Sumatriptan 50-100 mg combined with an NSAID is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1, 2
• Oral sumatriptan provides headache response (reduction to mild or no pain) in 52-62% of patients at 2 hours versus 17-27% with placebo 5
• 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
• 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, use non-oral routes 1, 4, 2
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% complete pain relief by 2 hours) with onset within 15 minutes, compared to only 50-67% response for oral formulations 1, 2
• 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 through central dopamine receptor antagonism 1, 2

IV Treatment for Severe Migraine in Urgent Care

• Metoclopramide 10 mg IV plus ketorolac 30 mg IV is first-line combination therapy for severe migraine requiring intravenous treatment 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 with a more favorable side effect profile (21% adverse events versus 50% with chlorpromazine) 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, 4, 2

• NSAIDs trigger medication overuse at ≥15 days/month; triptans at ≥10 days/month 2, 5
• Medication overuse headache presents as daily headaches or marked increase in migraine frequency 1, 5
• If requiring acute treatment more than twice weekly, initiate preventive therapy immediately 1, 2

Medications to Absolutely Avoid

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

Alternative Options When Triptans Fail or Are Contraindicated

CGRP Antagonists (Gepants)

• Ubrogepant 50-100 mg or rimegepant are primary oral alternatives for moderate to severe migraine when triptans are contraindicated, with no vasoconstriction making them safe for patients with cardiovascular disease 1, 4
• Ubrogepant has NNT of 13 for pain freedom at 2 hours 4

Ditans

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

Dihydroergotamine (DHE)

• Intranasal or IV dihydroergotamine has good evidence for efficacy as monotherapy 1, 4

Contraindications to Triptans

Triptans are contraindicated in patients with: 2, 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

Preventive Therapy Indications

Initiate 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
• Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura)

First-Line Preventive Medications

• Propranolol 80-240 mg/day has the strongest evidence for migraine prophylaxis 1, 2, 7
• Topiramate 100 mg/day is highly effective but requires discussion of teratogenic effects with women of childbearing potential 4, 2
• Amitriptyline 30-150 mg/day for patients with mixed migraine and tension-type headache 1, 2
• Avoid valproate in women of childbearing age due to teratogenic effects 1, 2
• OnabotulinumtoxinA 155 units is FDA-approved specifically 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, 2
• 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, 2
• Abandoning triptan therapy after single failed attempt—try different triptans or routes before declaring failure 1, 4
• Using acetaminophen alone—it has no efficacy for migraine as monotherapy 4, 2

Non-Pharmacologic Adjuncts

• Regular moderate to intense aerobic exercise (40 minutes three times weekly) is as effective as some preventive medications 4
• Cognitive-behavioral therapy, biofeedback, and relaxation training have good evidence for efficacy 4
• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 4