What medication is recommended for a patient with migraines?

Acute Migraine Treatment: Evidence-Based Medication Recommendations

For acute migraine treatment, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) for mild-to-moderate attacks, and use triptans (sumatriptan 50-100 mg, rizatriptan 10 mg, or eletriptan 40 mg) for moderate-to-severe attacks or when NSAIDs fail, with the combination of triptan plus NSAID providing superior efficacy to either agent alone. 1

First-Line Treatment Algorithm

Mild-to-Moderate Migraine Attacks

• Begin with NSAIDs as first-line therapy: ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg at migraine onset, ideally when pain is still mild 1
• Naproxen can be repeated every 2-6 hours as needed, with a maximum of 1.5 g per day, but limit use to no more than 2 days per week to prevent medication-overuse headache 1
• Consider adding an antiemetic (metoclopramide 10 mg or prochlorperazine 25 mg) 20-30 minutes before the NSAID to provide synergistic analgesia and improve outcomes 1

Moderate-to-Severe Migraine Attacks

• Escalate to triptans when NSAIDs fail after 2-3 migraine episodes or for moderate-to-severe attacks: 1

  • Sumatriptan 50-100 mg orally (NNT 6.1 for 50 mg, 4.7 for 100 mg for pain-free at 2 hours) 1, 2
  • Rizatriptan 10 mg (fastest oral triptan, reaching peak concentration in 60-90 minutes) 1
  • Eletriptan 40 mg (more effective with fewer adverse reactions than sumatriptan) 1, 3
  • Zolmitriptan 2.5-5 mg 1

• The combination of triptan plus NSAID is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1

Route Selection Based on Symptoms

• For patients with significant nausea or vomiting: use non-oral routes 1
  • Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% pain-free at 2 hours, NNT 2.3) with onset within 15 minutes 1, 4
  • Intranasal sumatriptan 20 mg (NNT 3.5 for headache relief at 2 hours) 1, 4
  • Rizatriptan orally disintegrating wafer 1

Emergency Department/IV Treatment Protocol

For severe migraine requiring IV treatment, use the combination of metoclopramide 10 mg IV plus ketorolac 30 mg IV as first-line therapy, providing rapid pain relief while minimizing side effects and rebound headache risk. 1

Standard IV Cocktail Components

• Metoclopramide 10 mg IV for direct analgesic effects through central dopamine receptor antagonism, plus antiemetic properties 1, 5
• Ketorolac 30 mg IV (60 mg IM for patients under 65 years) for rapid onset with approximately 6 hours duration and minimal rebound headache risk 1, 5
• Alternative antiemetic: prochlorperazine 10 mg IV, which is comparable in efficacy to metoclopramide 1

Second-Line IV Options for Refractory Cases

• Dihydroergotamine (DHE) 1 mg IV or intranasal for severe or refractory migraines after assessing response to first-line therapy at 30-60 minutes 1, 5
• Avoid opioids (hydromorphone, meperidine) or butalbital-containing compounds due to questionable efficacy, dependency risk, rebound headaches, and loss of efficacy over time 1

Critical Frequency Limitation

Strictly limit all acute migraine medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1

• NSAIDs trigger medication-overuse headache at ≥15 days/month 1
• Triptans trigger medication-overuse headache at ≥10 days/month 1
• Initiate preventive therapy immediately if the patient requires acute treatment more than twice weekly 1

When First Triptan Fails

If one triptan fails after 2-3 headache episodes, try a different triptan before abandoning the class, as failure of one does not predict failure of others. 1

Alternative Triptan Options

• Switch to rizatriptan 10 mg (fastest oral triptan), eletriptan 40 mg (more effective than sumatriptan), or zolmitriptan 2.5-5 mg 1
• Consider changing route: subcutaneous sumatriptan 6 mg provides 59% pain-free response versus only 50-67% for oral formulations 1, 4
• Naratriptan has the longest half-life, which may decrease recurrence headaches 1

Third-Line Options When All Triptans Fail

• CGRP antagonists (gepants): ubrogepant 50-100 mg or rimegepant as primary oral alternative when triptans are contraindicated or ineffective, with no vasoconstriction making them safe for patients with cardiovascular disease 1
• Lasmiditan (Reyvow) 50-200 mg: 5-HT1F receptor agonist without vasoconstrictor activity, but patients must not drive or operate machinery for at least 8 hours due to CNS effects 1

Contraindications Requiring Alternative Approach

Triptans and DHE are absolutely contraindicated in patients with: 1, 3

• Ischemic heart disease, angina pectoris, previous myocardial infarction, or coronary artery vasospasm (Prinzmetal's angina) 1, 3
• Uncontrolled hypertension 1, 3
• History of stroke, transient ischemic attack, hemiplegic or basilar migraine 3
• Peripheral vascular disease or ischemic bowel disease 3
• Wolff-Parkinson-White syndrome or arrhythmias with cardiac accessory conduction pathways 3

For these patients, use CGRP antagonists (ubrogepant, rimegepant) or lasmiditan as first-line alternatives. 1

Timing of Administration

Taking medication early, when pain is still mild, provides significantly better outcomes than waiting until pain is moderate or severe, with better NNTs for pain-free at 2 hours and sustained pain-free during 24 hours 1, 2

Common Pitfalls to Avoid

• Do not allow patients to increase frequency of acute medication use in response to treatment failure, as this creates a vicious cycle of medication-overuse headache; instead transition to preventive therapy while optimizing acute treatment strategy 1
• Do not abandon triptan therapy after a single failed attempt—if one triptan is ineffective, try a different triptan or different route of administration 1
• Do not use opioids or butalbital-containing compounds except when all other medications are contraindicated, as they lead to dependency, rebound headaches, and loss of efficacy 1
• Do not forget to assess for medication-overuse headache in patients using acute medications ≥10 days/month for triptans or ≥15 days/month for NSAIDs before escalating therapy 1

Preventive Therapy Indications

Initiate preventive therapy for patients with: 6

• Two or more migraine attacks per month producing disability lasting 3 or more days 6
• Use of abortive medication more than twice per week 6
• Contraindication to or failure of acute treatments 6
• Frequent migraine attacks that continue to impair quality of life despite optimized acute therapy 1