Initial Medication Management for Migraine-Associated Tinnitus

First-Line Treatment Options

The American Academy of Family Physicians recommends nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen sodium, or aspirin as first-line treatment for mild to moderate migraine attacks, with consistent evidence supporting their efficacy 1, 2
NSAIDs, including ibuprofen (400mg) 3, naproxen sodium 1, and aspirin 1, are effective for acute treatment of migraine with tinnitus 1, 2
Aspirin-acetaminophen-caffeine combination is more effective than acetaminophen alone, which is ineffective, for migraine treatment 1, 2

The American Academy of Family Physicians suggests starting with the lowest effective dose to minimize side effects 4
Monitoring for medication overuse, limiting acute treatments to no more than twice weekly, is crucial to prevent rebound headaches 5
Consider non-oral routes of administration if nausea/vomiting are significant components of the attacks 4

The American Academy of Family Physicians recommends triptans (serotonin 1B/1D agonists) for moderate to severe migraines, including sumatriptan (oral or subcutaneous) 3, rizatriptan 1, zolmitriptan 1, and naratriptan 1
Contraindications for triptans include uncontrolled hypertension, basilar or hemiplegic migraine, or risk for heart disease 4

The American Academy of Neurology recommends beta-blockers, such as propranolol (80-160 mg daily) or metoprolol, as first-line preventive options for frequent migraines 6, 7, 8
Tricyclic antidepressants, such as amitriptyline (10-100 mg at night), are also recommended as first-line preventive options 6, 7
Anticonvulsants, such as topiramate (50-100 mg daily), and angiotensin II receptor blockers, such as candesartan (16-32 mg daily), are also effective preventive options 6, 7
CGRP monoclonal antibodies, such as erenumab, fremanezumab, or galcanezumab, are newer preventive options for patients who fail first-line treatments 3

The initial approach should start with NSAIDs for acute attacks 5
If there is an inadequate response, add or switch to a triptan (if no contraindications) 3
For frequent attacks, initiate preventive therapy with propranolol, amitriptyline, topiramate, or candesartan 6

Evaluate treatment response within 2-3 months of initiation 7
Use headache calendars to track frequency, severity, and medication use 7
Assess for medication overuse, which can lead to rebound headaches 5
Consider dose adjustments or medication changes if inadequate response or intolerable side effects 8

Avoid acetaminophen alone as it is ineffective for migraine 1
Avoid opioids except as a last resort due to risk of dependence and medication overuse headache 2
Avoid excessive use of any acute medication (>2 days/week) to prevent medication overuse headache 5
Recognize that sodium valproate is contraindicated in women of childbearing potential due to teratogenic risk 6