Migraine may be treated either prophylactically (preventive) or abortively (rescue) for acute attacks.[1] Migraine is a complex condition; there are various preventive treatments which disrupt different links in the chain of events that occur during a migraine attack. Rescue treatments also target and disrupt different processes occurring during migraine.
Because of the complexity ofmigraine, no preventivetreatment modality is effective for allmigraine sufferers.[2]For example, lifestyle (including trigger avoidance), diet changes, diet supplements, and treating conditions such as sleep apnea may all help prevent migraines. Dental appliances such as theNociceptive Trigeminal Inhibition Tension Suppression System might be used in specific circumstances. Preventive treatments can be sub-divided into non-drug treatments, and treatment with medication. There are several non drug treatments suggested in the literature including weight control, management of migraine comorbidities, lifestyle modification, behavioural treatment and biofeedback, patient education, using headache diaries, and improving patients' knowledge about the disease.[3]
Rescue treatment involves acute symptomatic control with medication.[4] Recommendations for rescue therapy of migraine include: (1) migraine-specific agents such as triptans, CGRP antagonists, or ditans for patients with severe headaches or for headaches that respond poorly to analgesics, (2) non-oral (typically nasal or injection) route of administration for patients with vomiting, (3) avoid medication overuse headache by educating patients using prophylactic therapies.[5] Medications are more effective if used earlier in an attack.[4]
The frequent use of medication may result inmedication overuse headache (MOH), in which the headaches become more severe and more frequent.[6] This may occur withtriptans,ergotamines, andanalgesics, especiallyopioids ornarcotic analgesics.[6][7] Combination of opioids with other analgesics is thought to nearly double the risk of MOH.[8]
Spinal manipulation for treating an ongoing migraine headache is not supported by evidence.[9]
Ditans are a class of abortive medication for the treatment of migraines.[10] Oral lasmiditan (Reyvow) is approved in the US by the FDA for acute treatment of migraine in adults.[11]
Recommended initial treatment for those with mild to moderate symptoms are simple analgesics such asnon-steroidal anti-inflammatory drugs (NSAIDs) or the combination ofacetaminophen (paracetamol),acetylsalicylic acid (aspirin), andcaffeine, although caffeine overuse can be a contributor to migraine chronification as well as a migraine trigger for many patients.[12][13]Aspirin (900 to 1000 mg) can relieve moderate to severe migraine pain, with an effectiveness similar tosumatriptan.[14][15]Paracetamol, either alone or in combination withmetoclopramide (an anti-nausea drug), is an effective treatment with a low risk of adverse effects.[16][17] In pregnancy, paracetamol and metoclopramide are deemed safe as are NSAIDs until thethird trimester.[12] Intravenous metoclopramide is also effective by itself.[18][19]
Several NSAIDs, includingdiclofenac andibuprofen, have evidence to support their use.[20][21]Ibuprofen provides effective pain relief in about 50%.[22]Diclofenac has been found effective.Ketorolac is available in intravenous and intramuscular formulation.[12] The two mainadverse drug reactions (ADRs) associated with NSAIDs relate togastrointestinal (GI) effects andrenal effects of the agents.Naproxen by itself may not be effective as a stand-alone medicine to stop a migraine headache as it is only weakly better than a placebo medication in clinical trials.[23]
Triptans such assumatriptan are effective for both pain and nausea in up to 75% of migraineurs.[24][25][26] They are the initially recommended treatments for those with moderate to severe pain or those with milder symptoms who do not respond to simple analgesics.[12] The different forms available include oral, injectable,nasal spray, rectal, and oral dissolving tablets.[27][28][29][30] For people with migraine symptoms such as nausea or vomiting, taking the abortive medicine by mouth or through the nose may be difficult. All route of administration have been shown to be effective at reducing migraine symptoms, however, nasal and injectable subcutaneous administration may result in more side effects.[30][29] The adverse effects associated with rectal administration have not been well studied.[28] In general, all the triptans appear equally effective, with similar side effects. However, individuals may respond better to specific ones.[12]
Most side effects are mild, includingflushing; however, rare cases ofmyocardial ischemia have occurred.[27] They are thus not recommended for people withcardiovascular disease,[12] who have had a stroke, or have migraines that are accompanied by neurological problems.[31] In addition, triptans should be prescribed with caution for those with risk factors forvascular disease. While historically not recommended in those with basilar migraines there is no specific evidence of harm from their use in this population to support this caution.[32] Triptans are notaddictive, but may causemedication overuse headaches if used more than 10 days per month.[33][34]
Sumatriptan does not prevent other migraine headaches from starting in the future.[29] For increased effectiveness at stopping migraine symptoms, a combined therapy that includes sumatriptan andnaproxen may be suggested.[35]
The combinationmeloxicam/rizatriptan (Symbravo) was approved for medical use in the United States in January 2025.[36]
Ergotamine anddihydroergotamine are older medications still prescribed for migraines, the latter in nasal spray and injectable forms.[27][37] They appear equally effective to the triptans,[38][39] are less expensive,[40][39] and experience adverse effects that typically are benign.[41][42] In the most debilitating cases, such as those with status migrainosus, they appear to be the most effective treatment option.[41][42] The most common adverse effects are nausea, vomiting, abdominal pain, generalized weakness, tiredness, malaise, paresthesia, coldness, muscle pains, diarrhea, and chest tightness. These are less common with DHE than with ergotamine tartrate.[43] Ergots can cause vasospasm including coronary vasospasm, and are contraindicated in people with coronary artery disease.[44]
Phenothiazines, often used for the treatment of nausea and vomiting, are also effective for treating migraine headache.[45][46]Prochlorperazine is typically used due to a more favorable treatment profile.[47]
Gepants may be used for rescue as well as prevention. Some gepants are approved for different purposes in different jurisdictions.Zavegepant was approved for medical use in the United States in March 2023.[48][49][50]
Intravenousmetoclopramide, intravenousprochlorperazine, or intranasallidocaine are other potential options.[12][19] Metoclopramide or prochlorperazine are the recommended treatment for those who present to the emergency department.[12][19]Haloperidol may also be useful in this group.[19][37] A single dose of intravenousdexamethasone, when added to standard treatment of a migraine attack, is associated with a 26% decrease in headache recurrence in the following 72 hours.[51][52] Spinal manipulation for treating an ongoing migraine headache is not supported by evidence.[53] It is recommended thatopioids andbarbiturates not be used due to questionable efficacy, addictive potential, and the risk ofrebound headache.[12][54] There is tentative evidence thatpropofol may be useful if other measures are not effective.[55]
Magnesium is recognized as an inexpensive, over-the-counter supplement which can be part of a multimodal approach to migraine reduction. Some studies have shown to be effective in both preventing and treating migraine in intravenous form.[56] The intravenous form reduces attacks as measured in approximately 15–45 minutes, 120 minutes, and 24-hour time periods, magnesium taken orally alleviates the frequency and intensity of migraines.[57][58]
The combinationmeloxicam/rizatriptan (Symbravo) was approved for medical use in the United States in January 2025.[36]
For children, ibuprofen or other NSAIDs help decrease pain.[59][60] Triptans are effective, though there is a risk of side effects such as nausea, coronary vasoconstriction, dizziness, paresthesia, flushing, tingling, neck pain, and chest tightness, known as "triptan sensations".[61] Additionally, a combination of Cognitive Behavioral Therapy, biofeedback, and relaxation may decrease migraine frequency in children.[62]
Occipital nerve stimulation may be effective but has the downsides of being cost-expensive and has a significant amount of complications.[63]
There is modest evidence for the effectiveness of non-invasive neuromodulatory devices, behavioral therapies andacupuncture in the treatment of migraine headaches.[54] There is little to no evidence for the effectiveness of physical therapy,chiropractic manipulation and dietary approaches to the treatment of migraine headaches.[54] Behavioral treatment of migraine headaches may be helpful for those who may not be able to take medications (for example pregnant women).[54]
A PCORI systematic review released in September 2024 evaluated the viability of behavioral interventions for migraine prevention and found that all of or some combination ofCBT,relaxation training, and education could yield positive outcomes for reducing the frequency of migraines on the scale of migraine days per month.[62] The reduction with these non-pharmaceutical, non-surgical interventions was estimated to be about 1 migraine day/month which met the minimum clinical significance threshold.[62] The study also discovered that mindfulness-based stress reduction (MBSR) can potentially reduce the level of disability caused by migraines more than by providing education.[62] Furthermore, the study found that cognitive behavioral therapy combined with relaxation training may lead to a higher frequency of migraine attacks compared to propranolol, but it might also result in improved quality of life.[62] Studies have not sufficiently proven notable effects of behavioral interventions being administered through telehealth compared to inactive control.[62]
^abBartleson JD, Cutrer FM (2010). "Migraine update. Diagnosis and treatment".Minn Med.93 (5):36–41.PMID20572569.
^Ashina M, Buse DC, Ashina H, Pozo-Rosich P (2021). "Migraine: Integrated approaches to clinical management and emerging treatments".Lancet.397 (10283):1505–1518.doi:10.1016/S0140-6736(20)32342-4.PMID33773612.
^Eken C (March 2015). "Critical reappraisal of intravenous metoclopramide in migraine attack: a systematic review and meta-analysis".The American Journal of Emergency Medicine.33 (3):331–7.doi:10.1016/j.ajem.2014.11.013.PMID25579820.
^Singh RB, VanderPluym JH, Morrow AS, Urtecho M, Nayfeh T, Roldan VD, et al. (December 2020).Acute Treatments for Episodic Migraine. AHRQ Comparative Effectiveness Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US).PMID33411427. Bookshelf ID: NBK566246.Archived from the original on 15 January 2021. Retrieved28 June 2021.
^abSumamo Schellenberg E, Dryden DM, Pasichnyk D, Ha C, Vandermeer B, Friedman BW, et al. (November 2012)."Acute Migraine Treatment in Emergency Settings".AHRQ Comparative Effectiveness Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US).PMID23304741. Report No.: 12(13)-EHC142-EF.Archived from the original on 23 August 2023. Retrieved28 July 2023.
^abMorren JA, Galvez-Jimenez, N (December 2010). "Where is dihydroergotamine mesylate in the changing landscape of migraine therapy?".Expert Opinion on Pharmacotherapy.11 (18):3085–93.doi:10.1517/14656566.2010.533839.PMID21080856.S2CID44639896.
^abMorren JA, Galvez-Jimenez N (December 2010). "Where is dihydroergotamine mesylate in the changing landscape of migraine therapy?".Expert Opinion on Pharmacotherapy.11 (18):3085–93.doi:10.1517/14656566.2010.533839.PMID21080856.S2CID44639896.
^Silberstein SD, Young WB (1995). "Safety and efficacy of ergotamine tartrate and dihydroergotamine in the treatment of migraine and status migrainosus. Working Panel of the Headache and Facial Pain Section of the American Academy of Neurology".Neurology.45 (3 Pt 1):577–84.doi:10.1212/wnl.45.3.577.PMID7898722.S2CID72696344.
^Callan JE, Kostic MA, Bachrach EA, Rieg TS (Oct 2008). "Prochlorperazine vs. promethazine for headache treatment in the emergency department: a randomized controlled trial".J Emerg Med.35 (3):247–53.doi:10.1016/j.jemermed.2007.09.047.PMID18534808.
