Migraine Treatment Approach

Acute Treatment

The American Academy of Neurology recommends a stepped approach for migraine treatment, starting with over-the-counter analgics for mild to moderate attacks, followed by triptans for moderate to severe attacks, and considering preventive treatment if attacks are frequent or disabling 1, 2
Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line treatment for mild to moderate migraine attacks, with well-documented efficacy 1
The American Academy of Family Physicians suggests using ibuprofen 400-800 mg every 6 hours for acute migraine treatment 3, 1
The American Academy of Neurology recommends using diclofenac potassium for mild migraine attacks, with proven efficacy 1
Acetaminophen alone has limited efficacy and should only be used in patients intolerant to NSAIDs 1, 4

The American Headache Society recommends preventive treatment for migraines that significantly interfere with daily activities, despite acute treatment, or for frequent or severe migraines 1, 5
Beta-blockers, such as atenolol, bisoprolol, metoprolol, and propranolol, are recommended as first-line preventive treatment for migraines 6, 7
The American Academy of Neurology suggests using topiramate 50-100 mg daily as a preventive treatment for migraines 6, 7
OnabotulinumtoxinA and monoclonal antibodies targeting CGRP, such as erenumab and fremanezumab, are recommended as third-line preventive treatment for chronic migraines 6, 7

The American College of Obstetricians and Gynecologists recommends considering preventive treatment for women with menstrually related migraines, using NSAIDs or triptans starting 2 days before the expected onset of menses 6, 7
Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk 6, 7

The American Academy of Neurology recommends evaluating treatment response within 2-3 months of initiation or change, using measures such as headache frequency, severity, and disability 7, 8
Headache calendars are useful for capturing these measures and require minimal time commitment if completed only on symptomatic days 7, 8

The American Academy of Neurology recommends avoiding overuse of acute medications, which can lead to medication-overuse headaches 1, 5
Limiting and closely monitoring the use of opioids and butalbital-containing analgesics is recommended 3, 4
Avoiding triptan use during the aura phase of a migraine attack is recommended 2
Valproate sodium is absolutely contraindicated in women of childbearing age 6, 7