What are the treatment options for an adult patient experiencing a migraine headache?

Treatment of Migraine Headache

For nonpregnant adults with moderate to severe acute migraine, start with combination therapy of a triptan plus an NSAID—this is the most effective first-line treatment, providing sustained pain relief in significantly more patients than either medication alone. 1

First-Line Treatment Algorithm

Initial Therapy: Triptan + NSAID Combination

• Combine a triptan with an NSAID immediately for moderate to severe migraine attacks, as this combination provides 130 additional patients per 1000 achieving sustained pain relief at 48 hours compared to triptan alone 2
• Recommended specific combinations:
  • Sumatriptan 50-100 mg + naproxen 500 mg 2, 3
  • Alternative NSAIDs include aspirin, celecoxib, diclofenac, or ibuprofen if naproxen is unavailable 2
• Begin treatment as soon as possible after migraine onset to maximize efficacy 2, 3

For Patients Who Cannot Tolerate NSAIDs

• Use triptan + acetaminophen 1000 mg as an alternative combination, though evidence is lower certainty than triptan + NSAID 1, 2

For Mild to Moderate Migraine

• Start with NSAID monotherapy first (ibuprofen 400 mg, naproxen 500 mg, or aspirin) 1, 4
• If inadequate response after 2-3 attacks, add a triptan to the NSAID regimen 1, 3

Triptan Selection Considerations

Formulation Choice Based on Symptoms

• Rizatriptan orally disintegrating tablet for patients with early nausea/vomiting (faster onset, peak concentration 60-90 minutes) 3
• Sumatriptan subcutaneous for severe attacks requiring fastest relief 5
• Dihydroergotamine intranasal spray for refractory cases 2

Dosing Parameters

• Sumatriptan oral: 25-100 mg single dose; if partial response, may repeat after 2 hours; maximum 200 mg per 24 hours 5
• Allow 2-3 headache episodes before abandoning a specific triptan to assess true efficacy 3

Second-Line Options for Treatment Failures

CGRP Antagonists (Gepants)

• Use rimegepant, ubrogepant, or zavegepant for patients not responding to triptan-NSAID combinations 2
• These are newer, more costly alternatives but effective when triptans fail 1

Critical Medications to AVOID

Never prescribe opioids or butalbital-containing medications for acute migraine due to:

• High risk of dependency 2
• Medication overuse headache 2
• Rebound headaches 2

Medication Overuse Headache Prevention

Strict frequency limits to prevent medication overuse headache:

• Triptans: ≤10 days per month 2, 3
• NSAIDs/acetaminophen: ≤15 days per month 2
• Total acute medication use: no more than twice weekly 3

If these thresholds are exceeded, detoxification may be necessary 1

Adjunctive Therapy

Antiemetics

• Treat nausea itself, not just vomiting—nausea is one of the most disabling migraine symptoms 1
• Metoclopramide 10 mg can be added to oral medications 6
• Paracetamol 1000 mg + metoclopramide 10 mg provides efficacy equivalent to sumatriptan 100 mg 6

Supportive Measures

• Provide quiet, dark environment 2
• Ensure adequate hydration with IV fluids if in urgent care setting 2

Special Population: Pregnancy

• Acetaminophen 1000 mg is first-line for pregnant patients 2
• Metoclopramide 10 mg is safe for nausea in second and third trimesters 2
• Avoid triptans—animal data suggests potential fetal harm 5

Contraindications to Triptans

Do not use triptans in patients with: 5

• Coronary artery disease or vasospasm
• History of stroke or TIA
• Hemiplegic or basilar migraine
• Peripheral vascular disease
• Uncontrolled hypertension
• Wolff-Parkinson-White syndrome
• Recent (within 24 hours) use of ergotamine or another triptan
• Recent (within 2 weeks) MAO-A inhibitor use
• Severe hepatic impairment

Discharge Planning

• Prescribe acetaminophen 1000 mg for home rescue medication 2
• Never prescribe opioids or butalbital for home use 2
• Educate about medication overuse thresholds 2
• Recommend lifestyle modifications: adequate hydration, regular meals, consistent sleep patterns, trigger identification 2

When to Consider Preventive Therapy

Evaluate for preventive therapy if: 1

• ≥2 attacks per month producing disability lasting ≥3 days per month
• Contraindication to or failure of acute treatments
• Using abortive medication more than twice per week
• Presence of hemiplegic migraine, prolonged aura, or migrainous infarction

First-line preventive agents: propranolol 80-240 mg/day, timolol 20-30 mg/day, amitriptyline 30-150 mg/day, or divalproex sodium 500-1500 mg/day 1