Definition and Overview
Migraine treatment is divided into acute therapy (aborting an ongoing attack) and preventive therapy (reducing attack frequency and severity). Treatment strategies are tailored to individual attack patterns, severity, frequency, and comorbidities [1].
Acute Treatment
Simple Analgesics and NSAIDs
Aspirin (1000 mg), ibuprofen (400-600 mg), and naproxen (500-750 mg) are effective for mild-to-moderate attacks. Early treatment at pain onset improves efficacy. Acetaminophen (1000 mg) is a second-line option [2].
Triptans
Triptans (sumatriptan, rizatriptan, zolmitriptan, eletriptan) are 5-HT1B/1D agonists and the gold standard for moderate-to-severe migraine. Most effective when taken early in the attack while pain is still mild. Approximately 60-70% of patients respond to oral triptans [3]. Contraindicated in uncontrolled hypertension, coronary artery disease, and cerebrovascular disease.
Gepants and Ditans
CGRP receptor antagonists (ubrogepant, rimegepant) and 5-HT1F agonists (lasmiditan) offer alternatives without vasoconstrictive effects, suitable for patients with cardiovascular contraindications to triptans [4].
Preventive Treatment
Indicated when attacks occur 4 or more days per month, attacks are severe or prolonged, or acute medications are ineffective or overused.
Oral Medications
- Beta-blockers: propranolol, metoprolol (first-line)
- Antiepileptics: topiramate, valproate
- Antidepressants: amitriptyline, venlafaxine
- Candesartan, flunarizine
CGRP Monoclonal Antibodies
Erenumab (anti-CGRP receptor), fremanezumab, galcanezumab, and eptinezumab (anti-CGRP ligand) are monthly or quarterly subcutaneous/IV injections. They reduce monthly migraine days by 50% or more in about 50% of patients [5].
OnabotulinumtoxinA (Botox)
FDA-approved for chronic migraine (15+ headache days/month). 31 injection sites across the head and neck every 12 weeks.
Neuromodulation
- Single-pulse TMS (sTMS): FDA-cleared for acute and preventive migraine treatment
- Non-invasive vagus nerve stimulation (nVNS): gammaCore device for acute and preventive use
- External trigeminal nerve stimulation (eTNS): Cefaly device for prevention
Medication Overuse Prevention
Limit acute medication use to no more than 2-3 days per week. Triptans: maximum 10 days/month. Simple analgesics: maximum 15 days/month. Keep a medication diary to track usage.
Lifestyle Management
- Identify and avoid personal triggers (keep a headache diary)
- Regular sleep schedule
- Regular aerobic exercise (150 minutes/week)
- Stress management techniques
- Adequate hydration and regular meals