Migraine Treatment Recommendations
Acute Treatment
For moderate to severe episodic migraine, start with combination therapy of a triptan plus an NSAID (or acetaminophen if NSAIDs are contraindicated), treating as early as possible after headache onset. 1
Treatment Algorithm for Acute Migraine
First-line approach:
- Begin with an NSAID (aspirin, celecoxib, diclofenac, ibuprofen, or naproxen) or acetaminophen at adequate dosing
- If insufficient pain relief with appropriate dosing, add a triptan (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan) to the NSAID or acetaminophen 1
- For mild episodic migraine, NSAID or acetaminophen alone (or their combination) may suffice 1
Second-line options (if combination triptan + NSAID/acetaminophen fails or is not tolerated):
- CGRP antagonists-gepants: rimegepant, ubrogepant, or zavegepant
- Ergot alkaloid: dihydroergotamine 1
Third-line option (if all above fail):
- Lasmiditan (ditan class) 1
Special circumstances:
- Severe nausea/vomiting: Use nonoral triptan formulation plus antiemetic 1
- Cardiovascular risk: Consider gepants or lasmiditan, which lack vasoconstrictive effects 2
Explicitly avoid:
- Do not use opioids or butalbital for acute episodic migraine 1
Critical Pitfalls in Acute Treatment
Medication overuse headache thresholds:
- NSAIDs: ≥15 days per month
- Triptans: ≥10 days per month
- Monitor for headache occurring ≥15 days/month for ≥3 months in patients with preexisting headache disorder 1
Key counseling points:
- Treat early after onset for maximum efficacy
- Different agents within the same class may work when others fail
- Route of administration and cost should guide specific drug selection 1
Preventive Treatment
For episodic migraine prevention (1-14 headache days/month), initiate monotherapy with one of the following based on patient-specific factors: topiramate, propranolol/metoprolol, amitriptyline, candesartan, or CGRP-targeted therapies (monoclonal antibodies or atogepant). 3
Preventive Treatment Options
The 2025 ACP guidelines provide conditional recommendations (low-certainty evidence) for multiple first-line preventive options 3:
Traditional preventive medications:
- Antiseizure medications: valproate, topiramate
- β-blockers: metoprolol, propranolol
- Tricyclic antidepressant: amitriptyline
- Angiotensin II-receptor blockers: candesartan, telmisartan
- ACE inhibitors: lisinopril
- SSRIs/SNRIs: fluoxetine, venlafaxine
CGRP-targeted therapies:
- Monoclonal antibodies: eptinezumab, erenumab, fremanezumab, galcanezumab (injectable)
- Oral gepants: atogepant, rimegepant (for prevention) 3, 4
Advantages of CGRP-Targeted Therapies
CGRP-targeted medications demonstrate favorable safety and tolerability profiles with improved adherence compared to traditional preventives 4, 5. These migraine-specific treatments benefit patients who failed non-specific preventive medications and do not require titration like traditional options 4.
When to Initiate Prevention
Consider preventive therapy when:
- Episodic migraine occurs frequently
- Acute treatment provides inadequate response
- Risk of medication overuse headache develops 1
Treatment Goals
Preventive therapy aims to:
- Reduce frequency, severity, duration, and disability of attacks
- Decrease need for acute treatment and medication overuse risk
- Enhance quality of life and reduce interictal burden 4
Non-Pharmacologic Options
Neuromodulation devices offer evidence-based alternatives for both acute and preventive treatment 6:
For acute treatment (weak recommendations):
- SAVI Dual
- Cefaly
- Relivion
- Nerivio
For preventive treatment (weak recommendations):
- gammaCore Sapphire
- Cefaly
- Nerivio
These devices are safe, well-tolerated, and lack drug interactions, making them valuable for patients preferring non-drug therapies or with contraindications to pharmacotherapy 7, 6.
Essential Lifestyle Modifications
Counsel all patients on:
- Adequate hydration
- Regular meals
- Consistent, sufficient sleep
- Regular moderate-to-intense aerobic exercise
- Stress management (relaxation techniques, mindfulness)
- Weight loss if overweight/obese
- Identification and modification of migraine triggers 1
Special Populations
Pregnancy and lactation:
- Discuss adverse effects of all pharmacologic treatments
- Treatment selection requires careful risk-benefit assessment 1
Patients with cardiovascular risk:
- CGRP antagonists (gepants) and lasmiditan lack vasoconstrictive effects, providing safer migraine-specific options for the >20% of adults with migraine at increased cardiovascular risk 2