What are the treatment options for a patient experiencing migraines?

Migraine Treatment

Start with NSAIDs or acetaminophen-aspirin-caffeine combination for mild-to-moderate attacks, escalate immediately to triptan plus NSAID combination for moderate-to-severe attacks, and strictly limit all acute medications to no more than 2 days per week to prevent medication-overuse headache. 1

First-Line Treatment Algorithm

For Mild-to-Moderate Migraine

• Begin with NSAIDs at adequate doses: ibuprofen 400-800 mg, naproxen sodium 500-825 mg, aspirin 1000 mg, or diclofenac potassium 1
• Acetaminophen 1000 mg is less effective than NSAIDs and should only be used when NSAIDs are contraindicated 1
• The combination of acetaminophen 500 mg + aspirin 500 mg + caffeine 130 mg is superior to acetaminophen alone and represents an effective over-the-counter option 1, 2
• Verify patients are using adequate doses before declaring treatment failure—many patients underdose NSAIDs 1

For Moderate-to-Severe Migraine

• Add a triptan to an NSAID immediately, or to acetaminophen when NSAIDs are contraindicated 1
• Triptan plus NSAID combination is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 3
• Specific triptans with strong evidence: sumatriptan 50-100 mg, rizatriptan 10 mg, eletriptan 40 mg, zolmitriptan 2.5-5 mg, naratriptan, almotriptan, frovatriptan 1
• Take medication as early as possible when headache is still mild—triptans are most effective during this window 1

Critical Frequency Limitation

Limit all acute migraine medications to no more than 2 days per week (10 days per month for triptans, 15 days per month for NSAIDs) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 1, 3

When First-Line Treatment Fails

If One Triptan Fails

• Try a different triptan—failure of one does not predict failure of others 1, 3
• Consider route change: subcutaneous sumatriptan 6 mg provides highest efficacy (59% complete pain relief at 2 hours) with onset within 15 minutes 1, 3, 4
• Intranasal formulations are useful when significant nausea or vomiting is present 1, 3

If All Triptans Fail or Are Contraindicated

• CGRP antagonists (gepants): rimegepant, ubrogepant 50-100 mg, or zavegepant nasal spray 1, 3
• Dihydroergotamine (DHE) intranasal or IV has good evidence for efficacy 1
• Lasmiditan (ditan) 50-200 mg for patients who do not tolerate or have inadequate response to all other treatments—patients must not drive for at least 8 hours after taking lasmiditan due to CNS effects 1, 3

Adjunctive Treatment for Nausea and Vomiting

• Metoclopramide 10 mg IV or oral provides direct analgesic effects through central dopamine receptor antagonism beyond its antiemetic properties 1, 3, 5
• Prochlorperazine 10 mg IV or 25 mg rectal effectively relieves headache pain and is comparable to metoclopramide 1, 3
• Consider non-oral triptan routes when severe nausea or vomiting is present 1

Emergency Department/Urgent Care "Headache Cocktail"

For severe migraine requiring IV treatment:

• Metoclopramide 10 mg IV for direct analgesic and antiemetic effects 3, 5
• Ketorolac 30 mg IV (or 60 mg IM if under 65 years) for rapid onset with 6-hour duration and minimal rebound risk 1, 3, 5
• IV fluids for hydration 5
• Avoid prednisone—corticosteroids are reserved for status migrainosus (continuous migraine lasting up to one week), not routine acute treatment 3, 5

Medications to Absolutely Avoid

Do not use opioids (meperidine, hydromorphone, oxycodone) or butalbital-containing compounds for acute episodic migraine—they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time 1, 3, 5

When to Initiate Preventive Therapy

Start preventive therapy immediately if:

• Patient experiences ≥2 attacks per month producing disability lasting ≥3 days per month 6
• Patient uses acute medications more than twice weekly 6
• Patient has contraindications to acute treatments 6
• Acute treatment does not provide adequate response despite optimization 1

First-line preventive options: topiramate, beta-blockers (propranolol 80-240 mg/day), or amitriptyline 30-150 mg/day 6

Special Populations

Pregnancy and Lactation

• Acetaminophen is the safest option during pregnancy 7
• Avoid NSAIDs in third trimester 8
• Discuss adverse effects of all pharmacologic treatments with patients of childbearing potential before initiating therapy 1
• Sumatriptan may be an option for selected pregnant patients and is compatible with breastfeeding 7

Cardiovascular Disease or Uncontrolled Hypertension

• Triptans are contraindicated in patients with ischemic vascular disease, vasospastic coronary disease, or uncontrolled hypertension 1, 3, 8
• Use NSAIDs, gepants (no vasoconstriction), or lasmiditan as alternatives 3

Lifestyle Modifications

Counsel all patients on non-pharmacologic measures:

• Stay well hydrated and maintain regular meals 1
• Secure sufficient and consistent sleep 1
• Regular moderate-to-intense aerobic exercise for 40 minutes three times weekly—as effective as topiramate or relaxation therapy for prevention 6
• Manage stress with relaxation techniques or mindfulness practices 1
• Pursue weight loss for those who are overweight or obese 1

Common Pitfalls to Avoid

• Do not allow patients to increase frequency of acute medication use in response to treatment failure—this creates medication-overuse headache; instead transition to preventive therapy 3
• Do not abandon triptan therapy after a single failed attempt—try different triptans or routes before declaring class failure 1, 3
• Do not use triptans during the aura phase—wait until headache begins 1
• Do not combine triptans with ergot alkaloids within 24 hours due to additive vasoconstrictive effects 3