Migraine Treatment Guidelines

Acute Treatment

The American Academy of Neurology recommends a stepped care approach starting with NSAIDs for mild to moderate attacks and triptans for moderate to severe attacks for reducing pain, disability, and improving quality of life 1, 2
NSAIDs with proven efficacy, such as aspirin, ibuprofen, and diclofenac potassium, should be used first for mild to moderate migraine attacks 1, 2
Triptans, including sumatriptan, rizatriptan, zolmitriptan, eletriptan, and almotriptan, are first-line for moderate to severe attacks or when NSAIDs fail 1, 2
Treating acute migraine early in the attack yields the best results 1, 3
For attacks with significant nausea or vomiting, non-oral routes of administration, such as subcutaneous or nasal spray triptans, are recommended 1, 2
Adding antiemetics like metoclopramide or prochlorperazine can help treat nausea and improve gastric motility 2, 4
If one triptan is ineffective, trying another triptan or a NSAID-triptan combination is suggested 1, 3

The American Headache Society recommends considering preventive therapy for patients with frequent migraines (≥4 headaches/month or ≥8 headache days/month) 5
Beta-blockers, such as propranolol, metoprolol, and timolol, are first-line preventive options 5
Anticonvulsants, including topiramate and divalproex sodium, are also first-line preventive options 5
Amitriptyline combined with cognitive behavioral therapy can be an effective preventive strategy 3

Identifying and managing environmental, dietary, and behavioral triggers is crucial for migraine prevention 1, 3
Limiting acute medication use to avoid medication overuse headache is essential, with NSAIDs limited to ≤15 days/month and triptans to ≤10 days/month 1
Triptans are contraindicated in patients with cardiovascular disease 2
Topiramate and valproate have teratogenic effects, and women of childbearing potential should be advised on effective birth control and folate supplementation 3
Opioids should be limited due to the risk of dependency, rebound headaches, and eventual loss of efficacy 4