What are the recommended acute and preventive treatments for migraine, including medication options and lifestyle measures?

Migraine Treatment: Acute and Preventive Management

Acute Treatment Algorithm

Mild to Moderate Migraine (First-Line)

Start with NSAIDs as your initial therapy for mild to moderate migraine attacks. 1, 2

• Ibuprofen 400-800 mg at onset, repeat every 6-8 hours as needed 1, 2
• Naproxen sodium 500-825 mg at onset, can repeat every 2-6 hours (maximum 1.5 g/day) 1, 2
• Aspirin 900-1000 mg at onset 2, 3
• Combination therapy (acetaminophen 250 mg + aspirin 250 mg + caffeine 65 mg): two tablets at onset for enhanced efficacy 1, 3
• Acetaminophen 1000 mg only if NSAIDs are contraindicated 2

Moderate to Severe Migraine (First-Line)

Combine a triptan with an NSAID from the start—this combination is superior to either agent alone. 1, 2

Oral triptan options:

• Sumatriptan 50-100 mg + naproxen 500 mg (strongest evidence for combination) 1, 2
• Rizatriptan 10 mg (fastest oral triptan, peak at 60-90 minutes) 1
• Eletriptan 40 mg or zolmitriptan 2.5-5 mg (more effective with fewer adverse effects than sumatriptan) 1
• Naratriptan (longest half-life, reduces recurrence) 1

Non-oral routes when nausea/vomiting present:

• Subcutaneous sumatriptan 6 mg (highest efficacy: 59% pain-free at 2 hours, onset within 15 minutes) 1, 2
• Intranasal sumatriptan 5-20 mg or zolmitriptan nasal spray 1, 2

Refractory or Severe Attacks Requiring IV Treatment

Use IV metoclopramide 10 mg + IV ketorolac 30 mg as your first-line IV combination. 1

• Metoclopramide provides direct analgesic effects beyond antiemetic properties 1
• Ketorolac has rapid onset with 6-hour duration and minimal rebound risk 1
• Prochlorperazine 10 mg IV is equally effective as metoclopramide 1
• IV dihydroergotamine (DHE) when triptans contraindicated 1, 3

Critical Medication-Overuse Prevention

Limit ALL acute medications to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache. 1, 2

• NSAIDs: medication-overuse headache develops at ≥15 days/month 2
• Triptans: medication-overuse headache develops at ≥10 days/month 2
• If using acute treatment >2 days/week, initiate preventive therapy immediately 1, 2

Medications to Absolutely Avoid

Never use opioids (hydromorphone, oxycodone, codeine) or butalbital-containing compounds for routine migraine treatment. 1, 4

• These agents have questionable efficacy, cause dependency, trigger rebound headaches, and lose effectiveness over time 1
• Reserve opioids only when all other evidence-based treatments are contraindicated, sedation is acceptable, and abuse risk has been formally assessed 1

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Preventive Therapy Indications

Initiate preventive therapy when any of the following criteria are met: 2, 5

• ≥2 migraine attacks per month causing disability lasting ≥3 days 2, 5
• Using acute medications >2 days per week 2
• Contraindication to or failure of acute treatments 2, 5
• Hemiplegic migraine, prolonged aura, or migrainous infarction 2
• Patient preference for prevention over frequent acute treatment 5

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Preventive Treatment Algorithm

First-Line Preventive Medications

Start with propranolol 80-240 mg/day as your initial preventive agent—it has the strongest evidence base. 4, 2

• Propranolol 80-240 mg/day (long-acting formulation) 4, 2
• Timolol 20-30 mg/day (alternative beta-blocker with strong evidence) 4, 2
• Topiramate 50-200 mg/day (titrate slowly to minimize side effects) 2
• Divalproex sodium 500-1500 mg/day or sodium valproate 800-1500 mg/day 2
• Candesartan (angiotensin receptor blocker with first-line evidence) 4

Critical contraindications:

• Propranolol: asthma, heart failure, significant bradycardia 4
• Topiramate/valproate: absolutely contraindicated in women of childbearing potential due to teratogenic risk; if prescribed, mandate effective contraception and folate supplementation 6, 4

Second-Line Preventive Medications

Switch to these agents if first-line treatments fail or are not tolerated: 4

• Amitriptyline 30-150 mg/day (preferred when comorbid depression, anxiety, insomnia, or mixed migraine/tension-type headache) 4, 2
• Flunarizine 5-10 mg daily (contraindicated in Parkinsonism or depression; can cause extrapyramidal symptoms in elderly) 4

Treatment Evaluation Timeline

Allow 2-3 months before declaring treatment failure—clinical benefits take time to manifest. 4, 5

• Define success as ≥50% reduction in attack frequency 4
• Use headache diaries to objectively track frequency, severity, and disability 4
• If first preventive fails after adequate trial, switch to a different class—failure of one does not predict failure of others 4

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Lifestyle and Non-Pharmacological Measures

Counsel all patients on trigger identification and avoidance: 6

• Keep a headache diary (paper or smartphone app) to identify patterns and triggers 1
• Address modifiable triggers: sleep deprivation, stress, tobacco, alcohol, excessive caffeine 1
• Limit caffeine intake to avoid withdrawal headaches, but recognize caffeine's role as adjunctive therapy in combination analgesics 1

Behavioral interventions (adjunct to pharmacotherapy): 6

• Cognitive behavioral therapy combined with amitriptyline shows enhanced efficacy 6
• Biofeedback and relaxation training as first-line preventive adjuncts 1

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Special Populations

Children and Adolescents

Use ibuprofen as first-line acute treatment; in adolescents, consider triptans. 6

• Ibuprofen for pain relief 6
• Adolescents: sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral 6
• If one triptan fails, try another or NSAID-triptan combination 6
• Discuss with families that placebo was as effective as studied medications in many pediatric trials before starting preventive therapy 6, 4

Pregnancy

Acetaminophen 1000 mg is the safest acute treatment during pregnancy. 7

• NSAIDs acceptable prior to third trimester 7
• Avoid all triptans, ergotamines, and valproate (teratogenic) 6
• Opioids reserved for refractory cases only 7

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Common Clinical Pitfalls

Pitfall 1: Allowing patients to increase acute medication frequency when treatment "stops working"

• This creates medication-overuse headache and guarantees treatment failure 1
• Instead, transition to preventive therapy while optimizing acute treatment strategy 1

Pitfall 2: Declaring triptan failure after a single unsuccessful attempt

• Failure of one triptan does not predict failure of others 1
• Try 2-3 different triptans (or change route of administration) before abandoning the class 1

Pitfall 3: Delaying preventive therapy in patients with frequent attacks

• If headaches occur >2 days/week, preventive therapy is mandatory—do not rely solely on acute treatment 1, 2

Pitfall 4: Prescribing valproate/topiramate to women of childbearing age without contraception counseling

• These agents are highly teratogenic; mandate effective birth control and folate supplementation 6, 4

Pitfall 5: Using opioids or butalbital compounds as routine migraine therapy

• These agents worsen long-term outcomes, cause dependency, and trigger medication-overuse headache 1, 4