From the Guidelines
Migraine treatment should start with over-the-counter medications like ibuprofen (400-600mg) or naproxen (500-550mg) at the first sign of headache, and if ineffective, prescription triptans such as sumatriptan (50-100mg orally) or rizatriptan (10mg) can be added, as recommended by the American College of Physicians in 2025 1. For acute treatment, the goal is to provide relief within 2 hours.
- If patients use an adequate dose of an NSAID or acetaminophen and still do not have sufficient pain relief, then add a triptan to an NSAID, or to acetaminophen when NSAIDs are contraindicated or not tolerated, as suggested by the American College of Physicians in 2025 1.
- Consider treating mild episodic migraine headache with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen, as recommended by the American College of Physicians in 2025 1.
- Although available comparative effectiveness data were uncertain, there is evidence supporting efficacy for CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine), which can be considered for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen, as noted in the 2025 guideline from the American College of Physicians 1.
- Preventive treatment is recommended for frequent migraines (4+ monthly) and includes propranolol (80-160mg daily), topiramate (50-100mg daily), or amitriptyline (10-50mg nightly), as suggested by previous guidelines 1.
- Lifestyle modifications are crucial: maintain regular sleep patterns, stay hydrated, avoid known triggers (alcohol, certain foods, stress), and practice stress management techniques, as emphasized in the 2025 guideline from the American College of Physicians 1.
- Keeping a headache diary helps identify triggers and evaluate treatment effectiveness, which is an essential part of managing migraines, as noted in the 2025 guideline from the American College of Physicians 1.
From the FDA Drug Label
The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. In all 3 trials, the percentage of patients achieving headache response 2 and 4 hours after treatment was significantly greater among patients receiving sumatriptan tablets at all doses compared with those who received placebo The estimated probability of achieving an initial headache response over the 4 hours following treatment in pooled Trials 1,2, and 3 is depicted in Figure 1.
Migraine Treatment with Sumatriptan:
- Sumatriptan is effective in the acute treatment of migraine headaches.
- The percentage of patients achieving headache response 2 and 4 hours after treatment is significantly greater with sumatriptan compared to placebo.
- Key doses of sumatriptan used in the trials were 25,50, and 100 mg.
- Headache response was defined as a reduction in headache severity from moderate or severe pain to mild or no pain.
- Sumatriptan also reduced the incidence of migraine-associated symptoms such as nausea, photophobia, and phonophobia 2.
From the Research
Migraine Treatment Options
- Acetaminophen, nonsteroidal anti-inflammatory drugs, triptans, antiemetics, ergot alkaloids, and combination analgesics have evidence supporting their effectiveness in the treatment of migraine 3
- Triptans are first-line treatments for moderate to severe migraines, while acetaminophen and nonsteroidal anti-inflammatory drugs are first-line treatments for mild to moderate migraines 3
- Migraine-specific triptans and migraine-nonspecific nonsteroidal antiinflammatory drugs (NSAIDs) have the best levels of evidence, and are recommended as the first-line medications for acute migraine attacks 4
Treatment Strategies
- The administration of acute medications should follow the concept of "stratified care" 4
- For mild to moderate migraine attacks, oral NSAIDs are the first choice; with oral aspirin, combination analgesics, intravenous/intramuscular NSAIDs as alternatives 4
- For moderate to severe attacks, oral or nasal spray triptans and ergotamine/caffeine compounds are recommended and should be administered in the early stage of migraine attacks 4
- Antiemetics can be used as supplement to alleviate nausea and vomiting 4
New Developments in Migraine Treatment
- The development of new classes of acute treatment, including the small-molecule calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan), expands available options 5
- Neuromodulation offers a nonpharmacologic option for acute treatment, with the strongest evidence for remote electrical neuromodulation 5
- Noninvasive neuromodulation represents a new, Food and Drug Administration-approved nonsignificant risk alternative for acute migraine therapy 6
Prophylactic Treatment
- Prophylactic treatment constitutes an important aspect of migraine management and includes avoidance of trigger factors and life style advice followed by consideration of medications 7
- The drugs of first choice are beta-blockers, flunarizine, topiramate, valproate and amitriptyline, while drugs of second choice with less efficacy and evidence are venlafaxine, gabapentin, naproxen, butterbur root, riboflavin and magnesium 7