Acute and Preventive Management of Migraine in Adults

Acute Treatment Strategies

• Early combination therapy (triptan + NSAID or acetaminophen) is recommended for moderate‑to‑severe migraine attacks, while NSAID monotherapy is sufficient for mild attacks. 1
• Mild attacks – treat with an NSAID (e.g., ibuprofen, naproxen, diclofenac) or acetaminophen, alone or in combination. Moderate‑to‑severe attacks – use a triptan (sumatriptan, rizatriptan, eletriptan, almotriptan, naratriptan, frovatriptan, or zolmitriptan) together with an NSAID (ibuprofen, naproxen, aspirin, diclofenac, or celecoxib). Severe attacks with nausea/vomiting – give a non‑oral triptan formulation (nasal spray or subcutaneous) plus an anti‑emetic. All require administration as soon as the headache phase begins, not during aura. 1, 2
• If first‑line combination therapy fails or is not tolerated, consider second‑line agents: CGRP‑targeted gepants (rimegepant, ubrogepant, zavegepant) or the ergot alkaloid dihydroergotamine. 1, 2
• Third‑line option for patients who cannot use or do not respond to the above is lasmiditan, a 5‑HT₁F (ditan) agonist. 1, 2
• Contraindicated acute agents – opioids and butalbital‑containing medications should never be prescribed for migraine attacks. 1, 2

Preventive Therapy Initiation

• Start preventive treatment when any of the following are present:
  
  • Severe, disabling headaches despite adequate acute therapy.
  • Use of acute medications exceeding recommended frequencies (risk of medication‑overuse headache).
• Medication‑overuse thresholds: ≥15 days/month of NSAIDs or ≥10 days/month of triptans. 1, 2

First‑Tier Preventive Options (Cost‑Effective, Well‑Tolerated)

• Beta‑blockers – propranolol, metoprolol, timolol.
• Topiramate.
• Amitriptyline. 3

Alternative Preventive Options (When First‑Tier Fails)

• ACE inhibitor – lisinopril.
• ARBs – candesartan, telmisartan.
• SSRI – fluoxetine. 3

Preventive Treatment Principles

• Begin at a low dose and titrate gradually.
• Allow a 2–3 month trial period before deeming a preventive ineffective, unless adverse effects mandate earlier change.
• Emphasize adherence; clinical improvement typically emerges over several weeks.
• When efficacy is comparable, prioritize less costly agents. 3

Lifestyle and Non‑Pharmacologic Measures

• Encourage adequate hydration and regular meal timing as supportive measures to reduce migraine frequency. 2

Special Considerations for Patients of Childbearing Potential

• Discuss potential teratogenic and lactation‑related risks of all migraine medications before prescribing.
• Review pregnancy‑category information for triptans and NSAIDs.
• Note that CGRP antagonists have limited safety data in pregnancy. 1, 2, 3

Common Pitfalls to Avoid

• Medication‑overuse headache – educate patients about the ≥15 days/month NSAID and ≥10 days/month triptan limits. 1, 2
• Delayed treatment – stress the importance of treating early in the headache phase. 1
• Premature discontinuation of preventives – avoid stopping before a 2–3 month trial unless intolerable side effects occur. 3
• Cost‑inefficient prescribing – select lower‑cost medications when efficacy is similar. 1, 3
• Monotherapy for moderate‑severe attacks – combination therapy is superior to single‑agent treatment. 1

Monitoring and Follow‑Up

• Use a headache diary to track attack frequency, medication use, and potential overuse.
• Reassess preventive regimens periodically to balance benefits, harms, and costs.
• Initiate preventive therapy when episodic migraine remains frequent despite optimal acute management. 3, 1