Migraine Treatment Strategies

Acute Treatment Approach

For acute migraine treatment, a stepped care approach should be used, starting with NSAIDs for mild to moderate attacks and progressing to triptans or combination therapy for moderate to severe attacks. 1, 2
Over-the-counter NSAIDs with proven efficacy include acetylsalicylic acid (aspirin), ibuprofen, and diclofenac potassium. 1, 3
Paracetamol (acetaminophen) has less efficacy and should be used only in patients who are intolerant of NSAIDs. 1
Combination analgesics containing caffeine can be effective for mild attacks. 3, 4
Triptans should be offered to patients for whom over-the-counter analgesics provide inadequate headache relief. 1, 5
Triptans are most effective when taken early in an attack while headache is still mild. 1
If one triptan is ineffective, others might still provide relief. 1
Combining a triptan with an NSAID or acetaminophen improves efficacy. 5, 6
Patients should begin treatment as soon as possible after migraine onset using combination therapy. 6

For patients who fail all available triptans or have contraindications to triptans, options include CGRP antagonists (gepants) like rimegepant, ubrogepant, or zavegepant; dihydroergotamine (DHE); or lasmiditan (ditan). 5, 6
Subcutaneous sumatriptan injection can be useful for patients who cannot take oral triptans due to vomiting. 1

Use non-oral routes of administration for patients with migraine accompanied by nausea/vomiting. 3, 7
Consider antiemetics like metoclopramide or prochlorperazine to treat accompanying nausea and improve gastric motility. 3, 4

Avoid opioids and butalbital-containing analgesics for migraine treatment. 5, 6
Limit acute medication use to prevent medication overuse headache (≤15 days/month for NSAIDs, ≤10 days/month for triptans). 5, 6

Consider preventive therapy for patients with: two or more attacks per month producing disability lasting 3+ days per month; contraindication to or failure of acute treatments; use of acute medication more than twice per week; or presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura). 7, 8

Address predisposing factors such as poor sleep quality, poor physical fitness, or stress. 1, 2
Maintain regular meals, stay well hydrated, and ensure sufficient sleep. 5, 6
Engage in regular physical activity, preferably moderate to intense aerobic exercise. 5, 6
Manage stress with relaxation techniques or mindfulness practices. 5, 6

The American Academy of Neurology recommends topiramate as an effective option for preventive treatment, but requires discussion of teratogenic effects with patients of childbearing potential 9
The American College of Physicians suggests considering an ACE inhibitor, an ARB, or an SSRI if recommended treatments are not tolerated or result in inadequate response, and to start preventive medications at a low dose and gradually increase until desired outcomes are achieved 10
The American College of Physicians also recommends monitoring treatment using a headache diary to determine treatment efficacy, identify analgesic overuse, and follow up on migraine progression, and to switch preventive treatment if an adequate response is not achieved during a reasonable trial period 10

The American Academy of Neurology recommends onabotulinumtoxinA 155 units for chronic migraine (≥15 headache days per month) as it is FDA-approved and effective based on large-scale, double-blind, placebo-controlled trials 11
The American Headache Society suggests that cognitive-behavioral therapy, biofeedback, and relaxation training should be offered to all patients as these have good evidence for efficacy and should be part of comprehensive management 11

Regular moderate to intense aerobic exercise (40 minutes three times weekly) is as effective as some preventive medications for migraine management 11
Engaging in regular exercise, managing stress with relaxation techniques or mindfulness practices, and identifying and reducing aggravating factors and triggers using a headache diary are recommended for migraine prevention 11

Chronic migraine is defined as ≥15 headache days per month, and it is essential to rule out secondary causes of headache before establishing a chronic migraine diagnosis 11
Limiting as-needed medication use and monitoring closely for medication overuse headache is crucial in chronic migraine management 11
OnabotulinumtoxinA is specifically FDA-approved and effective for chronic migraine based on large-scale, double-blind, placebo-controlled trials 11

The American College of Physicians strongly recommends aspirin-acetaminophen-caffeine combination as first-line therapy for mild to moderate migraine attacks, with a number needed to treat of 9 for pain freedom at 2 hours and 4 for pain relief at 2 hours, based on evidence from the Annals of Internal Medicine 12
Ubrogepant and rimegepant receive a weak recommendation with a number needed to treat of 13 for pain freedom at 2 hours, according to the Annals of Internal Medicine 12
Lasmiditan demonstrated robust benefit for pain freedom at 2 hours but has significant adverse effects, including driving restrictions and a number needed to harm of 4 for treatment-emergent adverse effects, as reported in the Annals of Internal Medicine 12