How Is Migraine Treatment Decided?
Migraine treatment is not one-size-fits-all. Treatment is divided into two strategies: acute (taken during an attack) and preventive (taken regularly to reduce frequency). A specialist will assess attack frequency, severity, accompanying symptoms, prior treatments, and cardiovascular history to determine the most appropriate approach.
Acute Migraine Treatments
Acute treatments are taken at the onset of an attack to stop or significantly reduce symptoms. The goal is relief within two hours.
Triptans (First-Line for Moderate to Severe Migraine)
Triptans work by constricting dilated cranial blood vessels and blocking CGRP release along the trigeminal nerve pathway. The most commonly used triptans include sumatriptan, rizatriptan, eletriptan, and zolmitriptan, and they come in several forms: tablets, nasal sprays, dissolving wafers, and injections under the skin. When nausea or a sluggish stomach makes swallowing pills unreliable, the non-oral options are the better choice. That said, triptans aren't suitable for everyone; they're off the table for people with heart disease, poorly controlled high blood pressure, or a history of stroke.
Gepants (CGRP Receptor Antagonists)
Gepants block the CGRP receptor without causing vasoconstriction, making them safe for patients who cannot use triptans. Approved options are ubrogepant (Ubrelvy) and rimegepant (Nurtec). Rimegepant is also approved for the prevention the only treatment cleared for both acute and preventive migraine use.
Ditans
Lasmiditan (Reyvow) targets the 5-HT1F receptor on trigeminal nerves rather than blood vessels, making it cardiovascular-safe. However, it causes significant CNS sedation; patients must not drive for eight hours after dosing.
NSAIDs and OTC Combinations
For mild to moderate migraine, ibuprofen, naproxen sodium, and aspirin/acetaminophen/caffeine combinations (e.g., Excedrin Migraine) are effective when taken early. Limit use to fewer than 15 days per month to avoid medication overuse headache.
Ergot Alkaloids
Dihydroergotamine (DHE) as a nasal spray, injection, or IV infusion is used for prolonged or refractory attacks. It acts on serotonin and adrenergic receptors and inhibits CGRP.
Antiemetics
Medications like metoclopramide, prochlorperazine, and domperidone do more than just settle the stomach they also help get the gut moving again, which means oral migraine medications actually get absorbed properly. On top of that, there's solid evidence that they help take the edge off the pain itself.
Preventive Migraine Treatments
Preventive treatment is worth considering when migraines are happening four or more times a month, when attacks are badly affecting daily life, or when nothing taken during an attack seems to help enough.
When to Start Preventive Treatment
Consider prevention if you have four or more headache days per month, acute medications regularly fail, you have contraindications to acute drugs, you are using acute treatments more than 10 days per month, or attacks are prolonged or neurologically complex.
CGRP Monoclonal Antibodies (Newest Class)
CGRP antibodies are the first preventive drugs developed specifically for migraine. Approved options include erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality) given as monthly or quarterly self-injections and eptinezumab (Vyepti), a quarterly IV infusion. Clinical trials show they reduce monthly migraine days by 50% or more in roughly half of patients, with a generally low side-effect profile.
Traditional Oral Preventives
Before CGRP antibodies came along, prevention relied on medications borrowed from other conditions:
- Beta-blockers (propranolol, metoprolol) the go-to first choice, with a strong track record behind them.
- Amitriptyline a good option when migraines come alongside sleep problems or depression.
- Topiramate, valproate both work well, but come with some notable downsides; topiramate in particular, is known for causing a kind of mental fogginess.
- Verapamil is particularly used for cluster headache prevention
OnabotulinumtoxinA (Botox)
Botox is FDA-approved for chronic migraine (15+ headache days per month, at least 8 migrainous). About 31 sites around the head and neck are injected every 12 weeks, blocking pain-signalling neurotransmitter release from trigeminal nerve fibres.
Non-Drug and Device-Based Treatments
Several non-pharmacological options are recognised as effective and are particularly useful for patients who want to reduce medication use or have contraindications to drug therapy.
Neuromodulation Devices
A few FDA-cleared devices are worth knowing about the Cefaly, which uses electrical stimulation and works for both acute attacks and prevention; the gammaCore, which stimulates the vagus nerve non-invasively for acute relief; and the SpringTMS, which uses magnetic stimulation and works especially well for migraines with aura.
Behavioural Therapies
There's solid clinical evidence that both CBT and biofeedback can genuinely reduce how frequently migraines hit, and they work best when used alongside medication, not as a replacement for it. Simple everyday habits, such as going to bed at the same time, not skipping meals, drinking enough water, and keeping stress in check, have all been shown to make a real difference in how much migraines take over your life.
Medication Overuse Headache: A Treatment Risk to Know
MOH can creep up when acute medications are leaned on too heavily:
- Triptans, ergotamines, opioids, or combination analgesics, using them 10 or more days per month, is enough to trigger it.
- Simple analgesics or NSAIDs, the threshold is a bit higher, but 15 or more days per month puts you at risk.
MOH causes a paradoxical increase in headache frequency. Treatment requires withdrawal from the overused medication, which typically worsens headache temporarily, alongside initiation of preventive therapy.
Conclusion
Migraine treatment has advanced considerably. Patients now have a broader toolkit than ever from triptans and oral preventives to CGRP antibodies and neuromodulation devices.
The best results usually come from pairing a dependable acute treatment with a preventive strategy that actually fits your life, how often attacks happen, your daily routine, and your overall health history. If standard treatments aren't doing enough, a neurologist or headache specialist is the right person to talk to, since they'll know what newer options might be worth trying.
