What are the treatment options for migraines?

From the Guidelines

Migraines can be effectively treated with a combination of medication and lifestyle modifications, prioritizing ibuprofen or naproxen for acute mild attacks and triptans like sumatriptan or rizatriptan for moderate to severe attacks, as recommended by the most recent guidelines 1. For acute treatment, over-the-counter pain relievers like ibuprofen (400-600mg) or naproxen (500-550mg) can help mild attacks.

• Key considerations for acute treatment include:
  • Using medication early in the attack
  • Considering non-oral triptans for quick pain spikes or nausea/vomiting
  • Adding anti-emetics for nausea/vomiting For moderate to severe migraines, triptans such as sumatriptan (50-100mg orally) or rizatriptan (10mg) are often effective when taken at the first sign of headache.
• Anti-nausea medications like metoclopramide (10mg) can address associated symptoms. For prevention in frequent sufferers, medications such as amitriptyline combined with cognitive behavioral therapy, topiramate, or other preventive treatments may be considered, as discussed in recent guidelines 1.
• Lifestyle modifications are crucial and include:
  • Maintaining regular sleep patterns
  • Staying hydrated
  • Avoiding known triggers (certain foods, alcohol, stress)
  • Practicing stress management techniques
  • Keeping a headache diary to identify personal triggers Migraines involve complex neurological processes, including blood vessel changes and inflammation, which is why different medications target various aspects of this cascade.
• For severe, persistent migraines unresponsive to standard treatments, consultation with a neurologist is recommended for specialized care options, as suggested by older but still relevant studies 1.

From the FDA Drug Label

Sumatriptan binds with high affinity to human cloned 5-HT1B/1D receptors Sumatriptan presumably exerts its therapeutic effects in the treatment of migraine headache through agonist effects at the 5-HT1B/1D receptors on intracranial blood vessels and sensory nerves of the trigeminal system, which result in cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release.

• Treatment of migraines: Sumatriptan is used for the treatment of migraine headaches, it works by binding to 5-HT1B/1D receptors, causing cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release 2.
• Key considerations: Before treating headaches in patients not previously diagnosed as migraineurs, and in migraineurs who present with atypical symptoms, exclude other potentially serious neurological conditions 2.
• Contraindications: Sumatriptan is contraindicated in patients with Wolff-Parkinson-White syndrome, arrhythmias, CAD, Prinzmetal’s variant angina, history of stroke or TIA, and uncontrolled hypertension 2.

From the Research

Medical Treatment for Migraines

• The American Headache Society (AHS) recommends triptans, acetaminophen, and non-steroid anti-inflammation drugs (NSAID) as effective treatments for acute migraine attacks 3.
• Migraine-specific triptans and migraine-nonspecific nonsteroidal antiinflammatory drugs (NSAIDs) have the best levels of evidence and are recommended as first-line medications for acute migraine attacks 3.
• The administration of these medications should follow the concept of "stratified care", with oral NSAIDs as the first choice for mild to moderate migraine attacks, and oral or nasal spray triptans and ergotamine/caffeine compounds for moderate to severe attacks 3.

Lifestyle Modifications for Migraine Management

• Lifestyle modifications, such as physical activity, management of obesity, a healthy diet, and adequate sleep, can significantly contribute to reducing the frequency and severity of migraine attacks 4, 5.
• A healthy lifestyle, including avoidance of drug abuse, is important to consider in the overall management strategies for migraine sufferers 4.
• The mnemonic SEEDS (sleep, exercise, eat, diary, and stress) can be used to guide lifestyle modification counseling for migraine patients 5.

Dietary Changes for Migraine Patients

• Diet may play a role in triggering migraine, but available evidence on migraine and diet is limited 6.
• When advising patients on dietary changes to improve migraine, it is essential to acknowledge the limits in evidence and the larger role that diet may play in lifestyle changes 6.
• A clinical approach to addressing diet with migraine patients should focus on current evidence and individualized guidance 6.