What is the recommended acute and preventive management for a typical adult with episodic migraine, including medication choices, dosing, and lifestyle modifications?

Migraine Management: Acute and Preventive Treatment

Acute Treatment Algorithm

For mild to moderate migraine, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) as first-line therapy; for moderate to severe migraine, immediately use combination therapy with a triptan (sumatriptan 50-100 mg) plus an NSAID (naproxen 500 mg), taken as early as possible when headache begins. 1, 2

First-Line Options by Attack Severity

Mild Migraine:

• NSAIDs alone: ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg 1, 2
• Acetaminophen 1000 mg only if NSAIDs are contraindicated (less effective than NSAIDs) 1
• Alternative: aspirin 250 mg + acetaminophen 250 mg + caffeine 65 mg 2

Moderate to Severe Migraine:

• Combination therapy is superior to monotherapy: sumatriptan 50-100 mg + naproxen 500 mg provides 130 additional patients per 1,000 achieving sustained pain relief at 48 hours compared to sumatriptan alone (NNT = 3.5) 1, 2
• Treat early when pain is still mild: ~50% become pain-free at 2 hours versus ~28% when delayed until moderate/severe pain 1

Second-Line: Alternative Triptans

If initial triptan fails after 2-3 attacks, try a different triptan—failure of one does not predict failure of others 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, may decrease recurrence) 1

Third-Line: Route Change or CGRP Antagonists

• Subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours, onset within 15 minutes) for rapid progression or vomiting 1, 3, 2
• Intranasal sumatriptan 5-20 mg when significant nausea/vomiting present 1, 3, 2
• CGRP antagonists (gepants): ubrogepant 50-100 mg or rimegepant only after triptan-NSAID combination fails 1

Adjunctive Antiemetics

• Metoclopramide 10 mg IV/oral provides direct analgesic effects beyond antiemetic properties; give 20-30 minutes before NSAID for synergistic benefit 1, 3, 2
• Prochlorperazine 10 mg IV comparable efficacy to metoclopramide with fewer side effects 1, 3

Critical Frequency Limitation

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, 2

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

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Preventive Therapy Algorithm

Indications for Preventive Therapy

Initiate preventive therapy when: 1, 4, 5

• ≥2 migraine attacks per month producing disability lasting ≥3 days
• Using acute medication >2 days per week
• Contraindications to or failure of acute treatments
• Severe debilitating headache despite adequate acute treatment
• Patient preference for prevention

First-Line Preventive Medications (Start Here)

The 2025 American College of Physicians guideline prioritizes cost-effective oral agents before expensive CGRP therapies. 1

Choose one based on comorbidities and contraindications:

• Beta-blockers (metoprolol or propranolol 80-240 mg/day): strongest evidence, FDA-approved 1, 4, 5
• Amitriptyline 30-150 mg/day: preferred for comorbid depression, anxiety, sleep disturbances, or mixed migraine/tension-type headache 1, 4, 5
• Valproate/divalproex 500-1500 mg/day: effective but strictly contraindicated in women of childbearing potential due to teratogenic risk 1, 4, 5
• Venlafaxine (SNRI): alternative first-line option 1

Start at low dose, gradually titrate to therapeutic dose, assess efficacy after 2-3 months. 1, 4, 5

Second-Line: Topiramate

Use topiramate only after inadequate response or intolerance to a trial of beta-blocker, valproate, venlafaxine, or amitriptyline because topiramate has higher frequency of adverse events despite similar efficacy 1

Third-Line: CGRP Therapies

CGRP monoclonal antibodies (eptinezumab, erenumab, fremanezumab, galcanezumab) or CGRP antagonist-gepants (atogepant, rimegepant) should be reserved until after failure of first-line oral agents due to substantially higher cost, despite similar net benefits 1

• Assess efficacy after 3-6 months for CGRP antibodies 1
• Patient preference for oral versus injectable formulations influences choice 1

Alternative Options if First-Line Fails

If recommended treatments not tolerated or inadequate response: 1

• ACE inhibitor (lisinopril)
• ARB (candesartan or telmisartan)
• SSRI (fluoxetine)

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Lifestyle Modifications

Before initiating pharmacologic prevention, explore modifiable triggers and emphasize lifestyle interventions: 1, 2

• Hydration: maintain adequate fluid intake 1, 2
• Sleep hygiene: regular, adequate sleep (7-9 hours) 1, 2
• Physical activity: regular moderate-to-intense aerobic exercise 2
• Stress management: relaxation techniques, mindfulness, biofeedback 1, 2
• Avoid excessive caffeine (can contribute to medication-overuse headache) 1

True trigger factors are often self-evident; avoid unnecessary avoidance behaviors that damage quality of life. 1

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Special Populations & Contraindications

Cardiovascular Disease

• Triptans are absolutely contraindicated in ischemic heart disease, previous MI, coronary vasospasm, uncontrolled hypertension, cerebrovascular disease, stroke/TIA history 1, 3, 2
• Use NSAIDs with caution; consider CGRP antagonists (gepants) as safe alternative (no vasoconstriction) 3

Pregnancy & Lactation

• Discuss adverse effects of pharmacologic treatments during pregnancy/lactation before initiating therapy 1
• Acetaminophen generally preferred for acute treatment 2
• Valproate strictly contraindicated due to teratogenic risk 1

Renal Impairment

• Avoid or reduce NSAID doses 1
• Ketorolac contraindicated if creatinine clearance <30 mL/min 3

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Chronic Migraine & Medication-Overuse Headache

Definition & Recognition

• Chronic migraine: ≥15 headache days per month for ≥3 months, with migraine features on ≥8 days 1, 6
• Medication-overuse headache: acute medication use ≥10 days/month (triptans) or ≥15 days/month (NSAIDs/acetaminophen) 1, 2

Management of Medication-Overuse Headache

Abrupt withdrawal of overused medication is preferred (except opioids); explain to patient that headache may temporarily worsen for 2-10 days. 1

• Do not substitute another acute medication during withdrawal 1
• Initiate preventive therapy immediately 1

Preventive Therapy for Chronic Migraine

Evidence-based options: 1

• Topiramate (first choice due to lower cost) 1
• OnabotulinumtoxinA 155-195 U across 31-39 sites every 12 weeks (only FDA-approved therapy specifically for chronic migraine; assess efficacy after 6-9 months) 1, 6
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) after failure of ≥2 other preventives 1

Refer patients with chronic migraine to specialist care. 1

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Medications to Absolutely Avoid

Never use opioids (hydrocodone, oxycodone, meperidine, hydromorphone) or butalbital-containing compounds for migraine because they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time 1, 3, 2, 7

• Reserve opioids only when all other evidence-based treatments are contraindicated, sedation is acceptable, and abuse risk formally assessed 1, 3, 2
• If opioid absolutely necessary, butorphanol nasal spray has better evidence than other opioids 3

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Common Pitfalls to Avoid

• Do not allow patients to increase frequency of acute medication use in response to treatment failure—this creates medication-overuse headache; instead transition to preventive therapy 1
• Do not abandon triptan therapy after single failed attempt—try different triptan or route before escalating 1, 2
• Do not delay preventive therapy while trialing multiple acute strategies when headaches occur >2 days/week 1
• Do not use triptans during aura phase—no evidence supports efficacy; wait until headache begins 1
• Do not conflate aggravating factors (worsen headache during attack, e.g., physical activity) with predisposing factors (increase susceptibility, e.g., poor sleep) 1

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Headache Diary & Follow-Up

• Use headache diary (paper or smartphone) to track attack frequency, identify triggers, and assess treatment efficacy 1, 2
• Reassess therapy after 2-3 months for preventive medications 1, 4, 5
• Switch preventive medication if inadequate response during reasonable trial period (generally 2-3 months) or earlier if adverse event occurs 1