What are the treatment options for a patient with migraines?

Migraine Treatment

For acute migraine, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin-acetaminophen-caffeine combination) for mild-to-moderate attacks, and escalate to a triptan combined with an NSAID for moderate-to-severe attacks, taken as early as possible when pain is still mild. 1, 2

First-Line Acute Treatment Algorithm

Mild to Moderate Migraine

• 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 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 a number needed to treat of 9 for pain freedom at 2 hours and 4 for pain relief at 2 hours 3, 2
• Never use acetaminophen alone—it is ineffective for migraine as monotherapy 2

Moderate to Severe Migraine

• Triptan + NSAID combination is superior to either agent alone and represents 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 either agent alone 1
• Oral sumatriptan achieves headache response (reduction to mild or no pain) in 52-62% of patients at 2 hours versus 17-27% with placebo 4
• Alternative oral triptans include rizatriptan 10 mg (fastest oral triptan, reaching peak in 60-90 minutes), eletriptan 40 mg, or zolmitriptan 2.5-5 mg 1

Route Selection Based on Symptoms

When Nausea or Vomiting is Present

• Use non-oral routes of administration 1, 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 through central dopamine receptor antagonism 1, 2

IV Treatment for Severe Migraine in Emergency Settings

• Metoclopramide 10 mg IV plus ketorolac 30 mg IV is first-line combination therapy for severe attacks 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 1

Critical Medication Frequency Limits 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. 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, 4
• 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 as they lead to dependency, rebound headaches, and loss of efficacy over time 1, 2, 5

• Opioids should only be reserved for cases where all other medications are contraindicated, sedation is not a concern, and abuse risk has been addressed 1
• Butorphanol nasal spray has better evidence than other opioids if one must be used 1

Contraindications to Triptans (Use Alternatives)

Triptans are contraindicated in patients with: 1, 2, 4

• 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

Alternative Options When Triptans Fail or Are Contraindicated

• CGRP antagonists (gepants): ubrogepant 50-100 mg or rimegepant have no vasoconstriction and are safe for patients with cardiovascular disease 1, 3
• Lasmiditan (ditan) 50-200 mg is a 5-HT1F receptor agonist without vasoconstrictor activity, but patients must not drive for at least 8 hours after taking it 1
• Dihydroergotamine (DHE) intranasal or IV has good evidence for efficacy as monotherapy 1

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 and is FDA-approved for migraine prophylaxis 1, 2, 6
• 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 is FDA-approved specifically for chronic migraine (≥15 headache days per month) 3
• Avoid valproate in women of childbearing age due to teratogenic effects 1, 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 2, 7
• 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, 2, 5
• Failing to try alternative triptans after one fails—failure of one triptan does not predict failure of others; try 2-3 different triptans before abandoning the class 1

Lifestyle Modifications as Adjunctive Therapy

• Regular moderate to intense aerobic exercise (40 minutes three times weekly) is as effective as some preventive medications 3
• Maintain regular meals, stay well hydrated, and ensure sufficient sleep 3
• Manage stress with relaxation techniques or mindfulness practices 3
• Cognitive-behavioral therapy, biofeedback, and relaxation training have good evidence for efficacy 3