Table 2.

Migraine medications: A) Acute migraine medications. B) Prophylactic migraine medications.

A)
TYPE	ACUTE MEDICATIONS
First line	Ibuprofen 400 mg, ASA 1000 mg, naproxen sodium 500–550 mg, acetaminophen 1000 mg
Second line	Triptans: oral sumatriptan 100 mg, rizatriptan 10 mg, almotriptan 12.5 mg, zolmitriptan 2.5 mg, eletriptan 40 mg, frovatriptan 2.5 mg, naratriptan 2.5 mg Subcutaneous sumatriptan 6 mg if the patient is vomiting early in the attack. Consider for attacks resistant to oral triptans Oral wafer: rizatriptan 10 mg or zolmitriptan 2.5 mg if fluid ingestion worsens nausea Nasal spray: zolmitriptan 5 mg or sumatriptan 20 mg if patient is nauseated Antiemetics: domperidone 10 mg or metoclopramide 10 mg for nausea
Third line	Naproxen sodium 500–550 mg in combination with a triptan
Fourth line	Fixed-dose combination analgesics (with codeine if necessary; not recommended for routine use)

B)

PROPHYLACTIC MEDICATIONS	STARTING DOSE	*TITRATION,^ DAILY DOSE INCREASE**	TARGET DOSE OR THERAPEUTIC RANGE^†	NOTES
First line
• propranolol	20 mg twice daily	40 mg/wk	40–120 mg twice daily	Avoid in asthma
• metoprolol	50 mg twice daily	50 mg/wk	50–100 mg twice daily	Avoid in asthma
• nadolol	40 mg/d	20 mg/wk	80–160 mg/d	Avoid in asthma
• amitriptyline	10 mg at bedtime	10 mg/wk	10–100 mg at bedtime	Consider if patient has depression, anxiety, insomnia, or tension-type headache
• nortriptyline	10 mg at bedtime	10 mg/wk	10–100 mg at bedtime	Consider if patient has depression, anxiety, insomnia, or tension-type headache
Second line
• topiramate	25 mg/d	25 mg/wk	50 mg twice daily	Consider as a first-line option if the patient is overweight
• candesartan	8 mg/d	8 mg/wk	16 mg/d	Few side effects; limited experience in prophylaxis
• gabapentin	300 mg/d	300 mg every 3–7 d	1200–1800 mg/d divided into 3 doses	Few drug interactions
Other
• divalproex	250 mg/d	250 mg/wk	750–1500 mg/d divided into 2 doses	Avoid in pregnancy or when pregnancy is possible
• pizotifen	0.5 mg/d	0.5 mg/wk	1–2 mg twice daily	Monitor for somnolence and weight gain
• onabotulinumtoxinA	155–195 units	No titration needed	155–195 units every 3 mo	For chronic migraine only (headache on ≥ 15 d/mo)
• flunarizine	5–10 mg at bedtime	No titration needed	10 mg at bedtime	Avoid in patients with depression
• venlafaxine	37.5 mg/d	37.5 mg/wk	150 mg/d	Consider for migraine in patients with depression
Over the counter
• magnesium citrate	300 mg twice daily	No titration needed	300 mg twice daily	Effectiveness might be limited; few side effects
• riboflavin	400 mg/d	No titration needed	400 mg/d	Effectiveness might be limited; few side effects
• butterbur	75 mg twice daily	No titration needed	75 mg twice daily	Effectiveness might be limited; few side effects
• coenzyme Q10	100 mg 3 times daily	No titration needed	100 mg 3 times daily	Effectiveness might be limited; few side effects

ASA—acetylsalicylic acid.
↵* Dosage can be increased every 2 wk to avoid side effects. For most drugs, slowly increase to the target dose; a therapeutic trial requires several months. The expected outcome is reduction not elimination of attacks.
↵† If the target dose is not tolerated, try a lower dose. If the medication is effective and tolerated, continue it for at least 6 mo. If several preventive drugs fail, consider a specialist referral.
Adapted from Toward Optimized Practice.¹⁰