Acute Migraine Treatment Guidelines

Initial Treatment

For moderate to severe migraine, the American College of Physicians recommends starting combination therapy with a triptan (sumatriptan 50-100 mg) plus an NSAID (naproxen 500-825 mg or ibuprofen 400-800 mg) as first-line treatment, taken as early as possible when headache begins 1
For mild migraine, the American Academy of Neurology suggests starting with an NSAID alone (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) or acetaminophen 1000 mg 1
Alternative treatment for mild migraine is a combination of aspirin 250 mg + acetaminophen 250 mg + caffeine 65 mg, as recommended by the American Headache Society 2

If first-line therapy fails after 2-3 attacks, try a different triptan within the class, as failure of one does not predict failure of others, according to the American College of Physicians 1
Consider route change (intranasal or subcutaneous) if oral formulations are ineffective, as suggested by the American Academy of Neurology 2

Limit all acute migraine medications to no more than 2 days per week, as recommended by the American Headache Society 1, 3, 4
NSAIDs/acetaminophen: medication overuse headache develops at ≥15 days/month, according to the American College of Physicians 1
Triptans: medication overuse headache develops at ≥10 days/month, as reported by the American Academy of Neurology 1

In pregnancy, acetaminophen is generally preferred, while triptans, NSAIDs, and ergot alkaloids should be avoided unless benefits clearly outweigh risks, as recommended by the American College of Obstetricians and Gynecologists 1
In cardiovascular disease, triptans are contraindicated, and NSAIDs should be used with caution, according to the American Heart Association 1, 4

Maintain hydration and regular meals, as suggested by the American Headache Society 1, 3
Ensure consistent sleep schedule (7-9 hours), as recommended by the American Academy of Sleep Medicine 1, 3
Regular moderate-to-intense aerobic exercise, as suggested by the American College of Sports Medicine 1, 3
Stress management with relaxation techniques or mindfulness, as recommended by the American Psychological Association 1, 3