What are the treatment options for migraines?

From the Guidelines

For the treatment of acute episodic migraine headache, consider using a specific NSAID (such as aspirin, celecoxib, diclofenac, ibuprofen, or naproxen) or triptan (like almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan) based on individualized decision making, taking into account patient preferences and factors such as route of administration and cost. When deciding on a treatment approach, several factors should be considered, including the severity of the migraine, patient preferences, and potential side effects of the medications.

• For mild episodic migraine headache, treatment with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen is recommended 1.
• In cases of moderate to severe acute episodic migraine headache, where patients do not tolerate or have an inadequate response to combination therapy of a triptan and an NSAID or acetaminophen, consider using CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) 1.
• The use of opioids or butalbital for the treatment of acute episodic migraine is not recommended due to potential adverse effects and the risk of medication overuse headache 1.
• For patients experiencing severe nausea or vomiting, consider using a nonoral triptan and an antiemetic to manage symptoms effectively 1.
• It is crucial to counsel patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy to improve efficacy, and to be aware of the potential for medication overuse headache 1.

From the FDA Drug Label

AIMOVIG is indicated for the preventive treatment of migraine in adults.

• Erenumab (SQ) is used for the preventive treatment of migraine in adults.
• The primary efficacy endpoint was the change from baseline in monthly migraine days at month 3.
• Erenumab (SQ) treatment demonstrated statistically significant improvements for key efficacy endpoints compared to placebo.
• Sumatriptan (PO) is used for the treatment of migraine attacks, but it is not used for preventive treatment.
• It is essential to note that sumatriptan (PO) has several contraindications, including patients with Wolff-Parkinson-White syndrome, arrhythmias, CAD, Prinzmetal’s variant angina, and a history of stroke or TIA.
• Erenumab (SQ) is administered via subcutaneous injection once monthly, while sumatriptan (PO) is taken orally.
• Patients should be carefully evaluated before treatment to exclude other potentially serious neurological conditions 2.

From the Research

Treatment Options for Migraines

• Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, antiemetics, ergot alkaloids, and combination analgesics have evidence supporting their effectiveness in the treatment of migraine 3
• NSAIDs and triptans are the mainstays of acute migraine therapy, and antiemetic drugs can be added as necessary 4
• Triptans, ergot derivatives, and NSAIDs have historically been the main acute treatments for migraine, with new classes of acute treatment including small-molecule calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan) 5

First-Line Treatments

• Acetaminophen and NSAIDs are first-line treatments for mild to moderate migraines 3, 6
• Triptans are first-line treatments for moderate to severe migraines 3, 6
• Oral NSAIDs are the first choice for mild to moderate migraine attacks, with oral aspirin, combination analgesics, intravenous/intramuscular NSAIDs as alternatives 7

Second-Line and Refractory Treatments

• Other medications such as dihydroergotamine and antiemetics are recommended for use as second- or third-line therapy for select patients or for those with refractory migraine 3
• Dihydroergotamine (DHE) is also suitable for selected patients 4
• Rescue medications (eg, dopamine antagonists, combination analgesics, and corticosteroids) may be useful for patients who do not respond well to NSAIDs or triptans alone 4

Special Considerations

• During pregnancy, migraine may be treated with acetaminophen or NSAIDs (prior to third trimester), or opiates in refractory cases 6
• Acetaminophen is the safest acute migraine drug during pregnancy, and acetaminophen with codeine is also an option 4
• Sumatriptan may be an option during pregnancy for selected patients and is compatible with breast-feeding 4