Migraine Treatment Options Without Opiates or Diphenhydramine

First-Line Treatment Options

The American Academy of Family Physicians recommends non-steroidal anti-inflammatory drugs (NSAIDs) as the first-line treatment option for most migraine sufferers when avoiding opiates and diphenhydramine 1, 2
Aspirin (650-1000 mg every 4-6 hours, max 4g daily) has consistent evidence for efficacy in treating mild to moderate migraines 1, 3
Ibuprofen (400-800 mg every 6 hours, max 2.4g daily) is effective for mild to moderate migraine attacks 3, 4
Naproxen sodium (275-550 mg every 2-6 hours, max 1.5g daily) shows good efficacy in treating migraines 1, 3
Combination of acetaminophen-aspirin-caffeine is effective (acetaminophen alone is ineffective) in treating migraines 1, 2

Metoclopramide (10 mg IV or orally) can be used to treat accompanying nausea and improve gastric motility during migraine attacks 3, 4
Prochlorperazine can effectively relieve headache pain as well as nausea 4

The American Academy of Family Physicians recommends triptans as a second-line treatment option when NSAIDs fail to provide relief for moderate to severe migraines 1, 2
Rizatriptan, naratriptan, and zolmitriptan have good evidence for efficacy in treating migraines 1, 2
Dihydroergotamine (DHE) nasal spray has good evidence for efficacy and safety in treating migraines, particularly when nausea/vomiting is present early in the attack 1, 2

The American Academy of Family Physicians recommends propranolol (80-240 mg daily) as a first-line preventive medication for migraines, with strong evidence for efficacy 1, 5
Timolol (20-30 mg daily) is effective with tolerable side effects in preventing migraines 1, 5
Amitriptyline (30-150 mg daily) is recommended as a first-line preventive agent for migraines 1, 5
Divalproex sodium (500-1500 mg daily) or sodium valproate (800-1500 mg daily) are effective options for preventing migraines 1, 5

The American Academy of Family Physicians recommends considering preventive treatment for migraines when there are two or more migraine attacks per month with disability lasting 3+ days per month 1, 2
Use of acute medications more than twice per week is an indication for preventive treatment 1, 5
Failure of or contraindications to acute treatments is an indication for preventive treatment 2
Presence of uncommon migraine conditions (e.g., hemiplegic migraine, prolonged aura) is an indication for preventive treatment 1, 5
Limiting acute treatment to no more than twice a week can prevent medication overuse headaches 1, 5
Selecting a non-oral route of administration when significant nausea or vomiting is present early in the attack is recommended 1, 2

The American Academy of Family Physicians recommends avoiding triptans in patients with uncontrolled hypertension, coronary artery disease, basilar or hemiplegic migraine 1
NSAIDs should be used with caution in patients with gastrointestinal issues, renal impairment, or aspirin/NSAID-induced asthma 3