What are the treatment options for a patient experiencing migraine headaches?

Treatment for Migraine Headache

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

For Mild to Moderate Attacks

• Ibuprofen 400-800 mg every 6 hours is the most effective over-the-counter option, with 52-57% achieving 2-hour headache relief versus 25-37% with placebo 1, 3
• Naproxen sodium 500-825 mg provides longer duration of action and can be repeated every 2-6 hours, with a maximum of 1.5 g per day 1, 2
• Aspirin 650-1000 mg every 4-6 hours has proven efficacy 2
• Aspirin-acetaminophen-caffeine combination has a number needed to treat of 9 for pain freedom at 2 hours 1, 2
• Never use acetaminophen alone—it is ineffective for migraine as monotherapy despite some evidence showing benefit in population-based samples 2, 4

For Moderate to Severe Attacks

• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1
• Rizatriptan 10 mg reaches peak concentration in 60-90 minutes, making it the fastest oral triptan 1
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% complete pain relief by 2 hours) with onset within 15 minutes, particularly useful for rapid progression or severe nausea 1, 2, 5

Route Selection Based on Symptoms

When nausea or vomiting is present, non-oral routes are essential:

• Subcutaneous sumatriptan 6 mg for fastest relief (15 minutes onset) 1, 2
• Intranasal sumatriptan 5-20 mg as 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

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, which presents as daily headaches or marked increase in migraine frequency. 1, 2, 6

• NSAIDs trigger medication overuse at ≥15 days/month 2, 6
• Triptans trigger medication overuse at ≥10 days/month 2, 6
• If requiring acute treatment more than twice weekly, initiate preventive therapy immediately 1, 2

Alternative Options When First-Line Fails

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
• Eletriptan 40 mg or zolmitriptan 2.5-5 mg are reportedly more effective with fewer adverse reactions than sumatriptan 1
• Naratriptan has the longest half-life, which may decrease recurrent headaches 1

CGRP Antagonists (Gepants)

• Ubrogepant 50-100 mg or rimegepant are recommended as primary oral alternatives when triptans are contraindicated, with no vasoconstriction making them safe for cardiovascular disease 1, 6

Lasmiditan (Ditan)

• Lasmiditan 50-200 mg is a 5-HT1F receptor agonist without vasoconstrictor activity, safe for cardiovascular disease, but patients must not drive or operate machinery for at least 8 hours due to CNS effects 1, 6

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, 2, 6

Contraindications to Triptans (Use Alternatives)

Triptans are contraindicated in:

• Ischemic heart disease or previous myocardial infarction 1, 2
• Prinzmetal's variant angina or coronary artery vasospasm 2
• Wolff-Parkinson-White syndrome or cardiac accessory pathway disorders 2
• History of stroke or transient ischemic attack 2
• Uncontrolled hypertension 1, 2, 6
• Hemiplegic or basilar migraine 2

When to Initiate Preventive Therapy

Start preventive therapy when:

• Using acute medications more than twice per week 1, 2
• Two or more attacks per month producing disability lasting 3 or more days 1, 7
• Contraindication to or failure of acute treatments 2, 7

First-Line Preventive Medications

• Propranolol 80-240 mg/day has the strongest evidence 1, 2, 7
• Topiramate 100 mg/day is highly effective but requires discussion of teratogenic effects with women of childbearing potential 1, 2, 7
• Amitriptyline 30-150 mg/day for patients with mixed migraine and tension-type headache 1, 2, 7
• 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, 2
• Using acetaminophen alone—it has no efficacy for migraine as monotherapy 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
• Prescribing opioids or butalbital compounds—these worsen long-term outcomes and should be avoided 1, 2, 6