What pain relief can be given for migraine?

Can You Give Analgesia for Migraine?

Yes, you should absolutely give analgesia for migraine—start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) or acetaminophen 1000 mg as first-line therapy for mild to moderate attacks, and add a triptan (sumatriptan 50-100 mg) to the NSAID for moderate to severe attacks or when NSAIDs alone fail. 1, 2

First-Line Treatment Algorithm

For Mild to Moderate Migraine

• Start with NSAIDs or acetaminophen as your initial approach, with NSAIDs being superior to acetaminophen for most patients 1, 3
• Specific evidence-based options include:
  • Ibuprofen 400-800 mg (can repeat every 6 hours) 2, 3
  • Naproxen sodium 500-825 mg (provides up to 12 hours duration) 1, 2
  • Aspirin 1000 mg 1, 4
  • Acetaminophen 1000 mg (NNT of 12 for 2-hour pain-free response, inferior to NSAIDs but useful when NSAIDs are contraindicated) 1, 5

For Moderate to Severe Migraine

• Add a triptan to your NSAID regimen rather than switching completely—combination therapy is superior to either agent alone 1, 2
• The combination of sumatriptan 50-100 mg plus naproxen 500 mg provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to triptan alone 2
• If NSAIDs are contraindicated, combine triptan with acetaminophen 1

Triptan Selection and Dosing

• Sumatriptan 50-100 mg is the most studied option, with 61% achieving headache response at 2 hours with the 50 mg dose 6
• If one triptan fails after 2-3 headache episodes, try a different triptan—failure of one does not predict failure of others 2, 4
• Alternative triptans include rizatriptan 10 mg (fastest oral triptan, reaching peak in 60-90 minutes), eletriptan 40 mg, or zolmitriptan 2.5-5 mg 2
• Allow at least 2 hours between doses; maximum daily dose is 200 mg sumatriptan in 24 hours 6

Route of Administration Based on Symptoms

Oral Route (Standard)

• Use for patients without significant nausea or vomiting 1, 2
• Take medication as early as possible during the attack while pain is still mild for maximum effectiveness 1, 4

Non-Oral Routes

• For severe nausea/vomiting: Use subcutaneous sumatriptan 6 mg (provides highest efficacy with 59% complete pain relief by 2 hours, onset within 15 minutes) or intranasal formulations 2, 4
• Add an antiemetic (metoclopramide 10 mg IV or prochlorperazine 10 mg IV) for patients with significant nausea—these provide synergistic analgesia beyond just treating nausea 2

Third-Line Options for Refractory Cases

When combination therapy of triptan plus NSAID fails:

• CGRP antagonists (gepants): Rimegepant, ubrogepant, or zavegepant—no vasoconstriction, safe for cardiovascular disease 1, 2
• Dihydroergotamine (DHE): Intranasal or IV formulation with good efficacy evidence 1, 2
• Lasmiditan (ditan): Consider only when all other treatments have failed; patients cannot drive for 8 hours after use 1, 2

Critical Frequency Limitation to Prevent Medication-Overuse Headache

Limit all acute migraine medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache, which paradoxically worsens headache frequency and can lead to daily headaches 1, 2, 3, 4

• If patients require acute treatment more than twice weekly, initiate preventive therapy immediately (propranolol 80-240 mg/day, topiramate, or amitriptyline) rather than increasing acute medication frequency 2, 7

Medications to Absolutely Avoid

Do not use opioids or butalbital-containing compounds for acute migraine treatment—they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time 1, 2, 8

Common Pitfalls to Avoid

• Don't wait until pain is severe to take medication—early treatment while pain is mild significantly improves efficacy 1, 4
• Don't abandon triptan therapy after a single failed attempt—try a different triptan or different route of administration before declaring triptan failure 2, 4
• Don't increase dosage of acetaminophen beyond 1000 mg per dose or 4000 mg per day from all sources 1, 2
• Don't use triptans in patients with ischemic heart disease, uncontrolled hypertension, or significant cardiovascular disease—use gepants or DHE instead 2

Special Populations

Pregnancy and Lactation

• Acetaminophen is the safest option during pregnancy 9
• Sumatriptan may be considered for selected patients and is compatible with breastfeeding 9
• Discuss adverse effects of all pharmacologic treatments before initiating therapy in women of childbearing potential 1

Hepatic Impairment

• Maximum single dose of sumatriptan should not exceed 50 mg in mild to moderate hepatic impairment 6