What is the treatment for migraine (headache)?

From the Guidelines

Migraine treatment should be individualized, starting with NSAIDs or acetaminophen for mild episodes, and considering CGRP antagonists or ergot alkaloids for moderate to severe episodes, as recommended by the most recent guideline from the American College of Physicians 1.

Acute Treatment

For acute treatment, the following options are recommended:

• NSAIDs like ibuprofen or naproxen for mild episodes
• Combination therapy with a triptan and an NSAID or acetaminophen for moderate to severe episodes
• CGRP antagonists like rimegepant, ubrogepant, or zavegepant for moderate to severe episodes in nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy
• The ditan lasmiditan for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to all other pharmacologic treatments

Preventive Treatment

Preventive therapy is recommended for patients with frequent migraines or significant disability, and may include:

• First-line preventive medications like propranolol, topiramate, amitriptyline, or valproate
• CGRP antagonists like erenumab or fremanezumab for prevention
• Botulinum toxin injections for chronic migraine

Important Considerations

• Patients should be aware of medication overuse headache, which is a potential complication of migraine treatment 1
• Non-pharmacological approaches like trigger avoidance, regular sleep, stress management, and staying hydrated can also be helpful in managing migraine
• The most recent guideline from the American College of Physicians 1 provides the best evidence for individualized migraine treatment, and should be consulted for specific recommendations.

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. Zolmitriptan tablets are contraindicated in patients with CAD or Prinzmetal’s variant angina The estimated probability of achieving an initial headache response within 2 hours following treatment in pooled Studies 1,2,3, and 4 is depicted in Figure 1

Migraine Treatment Options:

• Sumatriptan: effective in treating migraine headaches by binding to 5-HT1B/1D receptors, causing cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release 2
• Zolmitriptan: contraindicated in patients with CAD or Prinzmetal’s variant angina, but may be effective in treating migraine headaches in other patients 3
• Rizatriptan: has been shown to be effective in treating migraine headaches, with an estimated probability of achieving an initial headache response within 2 hours following treatment 4

Key Considerations:

• Patients with CAD or Prinzmetal’s variant angina should not take zolmitriptan
• Sumatriptan and rizatriptan may be effective options for treating migraine headaches, but patients should be carefully evaluated for potential contraindications and side effects.

From the Research

Migraine Treatment Options

• Acute treatment for migraine is crucial for managing symptoms and preventing transformation to chronic migraine 5
• Various treatment options are available, including triptans, ergot derivatives, nonsteroidal anti-inflammatory drugs (NSAIDs), and neuromodulation 6, 7

Pharmacological Treatments

• Triptans are considered first-line treatment for moderate to severe migraines, while NSAIDs are recommended for mild to moderate migraines 7, 8
• Acetaminophen is suitable for mild to moderate migraine attacks and is the first choice for children and pregnant women 8
• Combination therapy, such as a triptan and an NSAID, may yield better efficacy than either therapy alone 8

Non-Pharmacological Treatments

• Neuromodulation offers a non-pharmacologic option for acute treatment, with the strongest evidence for remote electrical neuromodulation 6
• Noninvasive neuromodulation represents a new, Food and Drug Administration-approved nonsignificant risk alternative for acute migraine therapy 5

Treatment Strategies

• A stratified treatment approach is recommended, where patients are treated based on the severity of their migraine attacks 7, 8
• Taking medication early in an attack and using a stratified treatment approach can help ensure that migraine treatment is cost-effective 7
• The use of acute treatment should be limited to a maximum of ten days a month to prevent medication-overuse headache 8