Migraine Treatment

Acute Treatment

The American Academy of Neurology recommends nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy for mild to moderate migraine attacks, while triptans are first-line for moderate to severe attacks 1, 2, 3
NSAIDs inhibit cyclooxygenase enzymes, reducing prostaglandin synthesis and inflammation, with examples including aspirin, ibuprofen, and naproxen sodium 1, 2
Typical dosing for ibuprofen is 400-800mg every 6-8 hours as needed, and for aspirin is 900-1000mg as needed 1, 2
Triptans, such as sumatriptan and rizatriptan, activate serotonin receptors causing cranial vessel constriction and inhibition of vasoactive neuropeptide release, with typical dosing ranging from 25-100mg orally or 6mg subcutaneously for sumatriptan 4, 5
Ergot alkaloids, such as dihydroergotamine, are non-selective serotonin receptor agonists causing vasoconstriction, with typical dosing of 0.5-1mg IM/IV or intranasal 4

The American Academy of Neurology recommends beta blockers, such as propranolol, as first-line preventive agents for migraine, with a mechanism of action involving blockage of beta-adrenergic receptors 1, 6
Antidepressants, such as amitriptyline, increase synaptic serotonin and norepinephrine, with typical dosing of 30-150mg/day 1, 6
Anticonvulsants, such as divalproex sodium, enhance GABA activity and block sodium channels, with typical dosing of 500-1500mg/day 1, 6
Calcium channel blockers, such as flunarizine, block calcium influx and affect neurovascular function, with side effects including sedation and weight gain 7
Nutraceuticals, such as magnesium and riboflavin, have fair evidence for modest efficacy in migraine prevention, with mechanisms involving neurotransmission and mitochondrial function 8

The American Headache Society recommends considering non-oral routes of administration when nausea and vomiting are prominent symptoms, and limiting acute treatments to no more than twice weekly to prevent medication overuse headache 1, 3
Preventive therapy is indicated for patients with frequent or disabling migraine attacks, and a stepped care approach should be used, starting with NSAIDs for mild-moderate attacks and triptans for moderate-severe attacks 1, 2, 4
Triptans are most effective when taken early in an attack, but should not be taken during the aura phase 2

The American Academy of Family Physicians recommends selecting a non-oral route of administration when nausea is a significant component of migraine attacks, along with an antiemetic medication to treat the nausea 9, 10, 11
The American College of Physicians suggests adding an antiemetic medication to specifically target the nausea symptoms 9, 10
For mild to moderate attacks, the American Academy of Family Physicians recommends using NSAIDs via non-oral routes when possible 11, 12
For moderate to severe attacks, the American College of Physicians recommends using triptans via non-oral routes (e.g., sumatriptan subcutaneous injection or nasal spray) 11

The American Academy of Family Physicians notes that oral medications may have delayed absorption due to gastroparesis that often accompanies migraine attacks 12
The American College of Physicians advises that triptans should be avoided in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or significant cardiovascular disease 9
The American Academy of Family Physicians recommends limiting acute treatments to no more than twice weekly to prevent medication overuse headache 9

The American Academy of Family Physicians suggests that metoclopramide can treat nausea and improve gastric motility which may be impaired during migraine attacks 12
The American College of Physicians notes that antiemetics like prochlorperazine can effectively relieve both headache pain and nausea 12
The American College of Physicians recommends that antiemetics should not be restricted to patients who are vomiting, as nausea itself is one of the most disabling symptoms of migraine 10