Migraine Treatment Guidelines

First-Line Acute Treatment Options

The American College of Physicians recommends starting with NSAIDs (ibuprofen 400-800mg, naproxen sodium 500-825mg, or aspirin 650-1000mg) as first-line therapy for mild to moderate migraines 1, 2
For moderate to severe migraines or those unresponsive to NSAIDs, the American Academy of Neurology recommends using triptans (sumatriptan, rizatriptan, or zolmitriptan) as first-line treatment 1, 2
The American Headache Society suggests that oral options for triptans include sumatriptan, rizatriptan, naratriptan, and zolmitriptan 1, 2
Subcutaneous sumatriptan 6mg provides the highest efficacy (59% complete pain relief at 2 hours) but with higher adverse event rates 2
Rizatriptan reaches peak concentration fastest among oral triptans (60-90 minutes) 4

The American Gastroenterological Association recommends that antiemetics should not be restricted to patients who are vomiting—nausea itself is one of the most disabling symptoms and warrants treatment 1, 2
Metoclopramide 10mg IV or orally, given 20-30 minutes before or with analgesics/NSAIDs, provides synergistic analgesia beyond just treating nausea 4, 2
Prochlorperazine 10mg IV or 25mg orally/suppository effectively relieves headache pain comparable to metoclopramide 4, 2

The American Academy of Neurology recommends dihydroergotamine (DHE) nasal spray or parenteral formulations for severe migraines 1, 2
Combination therapy: NSAID plus triptan for patients with inadequate response to monotherapy 2
Opioids (butorphanol nasal spray, oral opioid combinations) should be reserved only when other medications cannot be used, sedation effects are not a concern, and risk for abuse has been addressed 1, 2

The American Headache Society recommends considering preventive therapy when patients have two or more attacks per month, contraindication to or failure of acute treatments, use of acute medications more than twice per week, or presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction) 1, 2, 3
First-line preventive medications include propranolol 80-240mg daily, timolol 20-30mg daily, amitriptyline 30-150mg daily, and divalproex sodium 500-1500mg daily or sodium valproate 800-1500mg daily 1, 3

The American Academy of Neurology warns that medication-overuse headache occurs with acute medication use more than twice weekly—this creates a vicious cycle of increasing headache frequency and daily headaches 1, 2, 3
Limit acute therapy to no more than 2 days per week, and if patients require acute treatment more frequently, transition to preventive therapy rather than increasing acute medication frequency 1, 2