Migraine Treatment Algorithm

Introduction to Migraine Treatment

The American Academy of Family Physicians recommends a stratified-care approach for acute migraine treatment, where treatment intensity matches attack severity, with NSAIDs or combination analgesics for mild-to-moderate attacks, and triptans for moderate-to-severe attacks, with early administration being critical for optimal efficacy 1

For mild-to-moderate migraine attacks, the American College of Physicians suggests NSAIDs as the initial treatment of choice, including aspirin, ibuprofen, naproxen sodium, or diclofenac potassium 1
Combination therapy with aspirin + acetaminophen + caffeine provides synergistic analgesia and enhanced absorption when NSAIDs alone are insufficient, as recommended by the American Academy of Neurology 1
The American Headache Society recommends beginning treatment as early as possible during the attack to maximize efficacy 1
For moderate-to-severe migraine attacks, the American College of Emergency Physicians suggests oral triptans as first-line, including sumatriptan 50-100 mg, rizatriptan 10 mg, naratriptan 2.5 mg, or zolmitriptan 2.5-5 mg 1

The American College of Emergency Physicians recommends metoclopramide 10 mg IV + ketorolac 30 mg IV as the first-line parenteral combination for severe attacks, providing rapid pain relief while minimizing rebound headache risk 1
Prochlorperazine 10 mg IV is equally effective as metoclopramide and may be substituted, according to the American Academy of Emergency Medicine 1

The American Headache Society recommends IV corticosteroids as the mainstay treatment for status migrainosus 2
IV fluids for hydration + antiemetic therapy (metoclopramide or prochlorperazine) are also recommended by the American College of Physicians 2

The American Academy of Neurology suggests limiting acute therapy to no more than 2 days per week to prevent medication-overuse headache 1
The American Headache Society recommends limiting NSAIDs to <15 days/month and triptans to <10 days/month to prevent medication-overuse headache 3

The American College of Cardiology recommends avoiding triptans and using NSAIDs or antiemetics as primary therapy in patients with cardiovascular disease 2
The American College of Obstetricians and Gynecologists suggests acetaminophen and antiemetics as preferred treatments during pregnancy, while avoiding NSAIDs and triptans 2

The American Academy of Family Physicians recommends relaxation training, thermal biofeedback combined with relaxation, electromyographic biofeedback, and cognitive-behavioral therapy as effective for migraine prevention 4
These behavioral therapies can be combined with preventive drug therapy for additional benefit, according to the American Academy of Neurology 4