Migraine Treatment Guidelines

Evidence-Based Pharmacological Treatments

The American College of Physicians recommends NSAIDs plus antiemetics as the first-line treatment for mild to moderate migraine attacks 1, 2
The American Academy of Neurology suggests triptans as the first-line treatment for moderate to severe migraine attacks 2, 3
Combination therapy with a triptan and an NSAID or acetaminophen should be initiated as soon as possible after migraine onset for improved efficacy, according to the American Headache Society 2
Beta blockers without intrinsic sympathomimetic activity, such as atenolol, bisoprolol, metoprolol, and propranolol, are recommended as first-line preventive treatments by the American Academy of Neurology 1, 4, 5
Topiramate and candesartan are also recommended as first-line preventive treatments by the American Academy of Neurology 1, 5
CGRP monoclonal antibodies, such as erenumab, fremanezumab, galcanezumab, and eptinezumab, are recommended as third-line preventive treatments by the American Headache Society 1, 3, 5

Non-invasive neuromodulatory devices may be considered for migraine treatment, although evidence is limited, according to the American Academy of Neurology 1, 6
Biobehavioural therapy and acupuncture may also be considered, although evidence suggests that acupuncture may not be superior to sham acupuncture, according to the American Headache Society 1

The American Academy of Neurology recommends assessing migraine frequency and severity to determine the need for preventive treatment, with a threshold of ≥2 days per month despite optimized acute treatment 1, 7, 2
For acute treatment, the American Headache Society recommends NSAIDs plus antiemetics for mild to moderate attacks, and triptans for moderate to severe attacks, with ditans or gepants considered if triptans fail 1, 7, 2
For preventive treatment, the American Academy of Neurology recommends beta blockers, topiramate, or candesartan as first-line options, with flunarizine, amitriptyline, or sodium valproate considered as second-line options, and CGRP monoclonal antibodies or CGRP antagonists-gepants considered as third-line options 1, 7, 5, 8

The American Academy of Neurology recommends avoiding opioids and butalbital for acute migraine treatment due to the risk of medication overuse headache 2
The American Headache Society notes that sodium valproate is strictly contraindicated in women of childbearing potential due to the risk of birth defects 1
Treatment efficacy for preventive medications should be assessed after 2-3 months of use, according to the American Academy of Neurology, with CGRP monoclonal antibodies requiring 3-6 months for assessment 7

The American College of Physicians recommends prescribing combination therapy with a triptan (sumatriptan 50-100 mg, rizatriptan 10 mg, or eletriptan 40 mg) PLUS naproxen sodium 500 mg to be taken at migraine onset, which is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 9
The American College of Physicians suggests strictly limiting all acute medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache, which can paradoxically worsen migraine frequency 9

The American College of Physicians states that medication-overuse headache (MOH) is defined as headache occurring ≥15 days per month for at least 3 months in patients with preexisting headache disorder due to overuse of acute medication, with the threshold varying by medication: ≥15 days/month for NSAIDs, ≥10 days/month for triptans 9

The American College of Physicians recommends maintaining regular sleep schedule with sufficient and consistent sleep 9
The American College of Physicians suggests staying well hydrated and maintaining regular meals 9
The American College of Physicians recommends engaging in regular moderate to intense aerobic exercise 9
The American College of Physicians suggests managing stress with relaxation techniques or mindfulness practices 9
The American College of Physicians recommends identifying and avoiding individual migraine triggers through detailed history 9