Migraine and Headache Treatments- MPR

Migraine and Headache Treatments

MIGRAINE AND HEADACHE TREATMENTS
Generic	Strength	Brand		Form	Dose
TREATMENT
Analgesic + Barbiturate
acetamin– ophen	325mg	—	Rx	caps, tabs	≥12yrs: 1–2 tabs or caps every 4hrs as needed; max 6/day. Not recommended for extended or repeated use. <12yrs: Not established.
butalbital	50mg
caffeine	40mg
acetamin– ophen	300mg	—	Rx	caps	Adults: 1–2 caps every 4hrs as needed; max 6 caps/day. Children: Not established.
butalbital	50mg
caffeine	40mg
acetamin– ophen	325mg	—	Rx	tabs	Adults: 1–2 tabs every 4hrs; max 6 tabs/day. Children: Not recommended.
butalbital	50mg	—	Rx	tabs
Analgesic + Barbiturate + Opioid
acetamin– ophen	325mg	Fioricet w. Codeine	CIII	caps	Adults: 1–2 caps every 4hrs as needed; max 6 caps/day. Children: Not established.
butalbital	50mg
caffeine	40mg
codeine phosphate	30mg
Analgesic + Salicylate
aspirin	500mg	Bayer Headache	OTC	caplets	≥12yrs: 2 caplets with a glass of water every 6hrs; max 8 caplets/24hrs. <12yrs: consult physician.
caffeine	32.5mg	Bayer Headache	OTC	caplets
acetamin– ophen	250mg	Excedrin Migraine	OTC	caplets	≥18yrs: 2 caplets with a glass of water; max 2 caplets/24hrs. <18yrs: Consult physician.
aspirin	250mg
caffeine	65mg
Barbiturate + Salicylate
aspirin	325mg	—	CIII	caps	Adults: 1–2 caps every 4hrs as needed; max 6 caps/day. Not recommended for extended or repeated use. Children: Not established.
butalbital	50mg
caffeine	40mg
Barbiturate + Salicylate + Opioid
aspirin	325mg	—	CIII	caps	Adults: 1–2 caps every 4hrs as needed; max 6 caps/day. Children: Not established.
butalbital	50mg
caffeine	40mg
codeine phosphate	30mg
Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist
galcanezumab-gnlm	100mg/mL, 120mg/mL	Emgality	Rx	soln for SC inj	Adults: Cluster headache: 300mg (three 100mg inj) at the onset of the cluster period, then monthly until the end of the cluster period. Children: Not established.
rimegepant	75mg	Nurtec ODT	Rx	ODT	Adults: 75mg once as needed (max daily dose). The safety of using more than 18 doses in a 30-day period has not been established. Children: Not established.
ubrogepant	50mg, 100mg	Ubrelvy	Rx	tabs	Adults: Initially 50mg or 100mg; may give a second dose ≥2hrs after initial dose (max 200mg/day). The safety of treating more than 8 migraines in a 30-day period has not been established. Children: Not established.
Ergot Alkaloid
dihydro– ergotamine mesylate	1mg/mL	—	Rx	IM, IV, or SC inj	Adults: 1mL IV at 1hr intervals; max 2 doses/day. Or, 1mL IM or SC at 1hr intervals; max 3 doses/day. For all: max 6 doses/wk. Not for chronic use. Children: Not established.
	4mg/mL	Migranal	Rx	nasal spray †	Adults: 1 spray in each nostril, repeat 15mins later; max 6 sprays/24hrs and 8 sprays/wk. Children: Not established.
	4mg/mL	Trudhesa	Rx	nasal spray †	Adults: 1 spray in each nostril, may repeat at least 1hr later if needed; max 2 doses (4 sprays) within 24hrs or 3 doses (6 sprays) within 7 days. Children: Not established.
ergotamine tartrate	1mg	—	Rx	tabs	Adults: 2 tabs at onset of attack, then 1 tab every ½hr if needed; max 6 tabs/attack, 10 tabs/wk. Children: Not recommended.
caffeine	100mg	—	Rx	tabs
ergotamine tartrate	2mg	—	Rx	rectal supp	Adults: 1 supp rectally at onset of attack, then 1 supp after 1hr if needed; max 2 supps/attack, 5 supps/wk. Children: Not recommended.
caffeine	100mg	—	Rx	rectal supp
Non-Steroidal Anti-inflammatory (NSAID)
celecoxib	25mg/mL	Elyxyb	Rx	oral soln	Adults: 120mg (4.8mL) once. Max: 120mg/day. Use for the fewest number of days per month, as needed. Moderate hepatic impairment, CYP2C9 poor metabolizers: max 60mg (2.4mL). Children: Not established.
diclofenac potassium	50mg	Cambia	Rx	buffered pwd for oral soln*	≥18yrs: Mix 1 packet (50mg) with 30–60mL of water only and drink immediately. Not interchangeable with other forms of diclofenac. <18yrs: Not recommended.
ibuprofen	200mg	Advil Migraine	OTC	liq-filled caps	≥18yrs: Usually 400mg once daily. Max 2 caps/24hrs. <18yrs: consult physician.
Selective 5-HT_1B/1D Receptor Agonist
almotriptan (as malate)	6.25mg, 12.5mg	—	Rx	tabs	≥12yrs: 6.25–12.5mg single dose; may repeat once after 2hrs; max 25mg/24hrs. Hepatic impairment, CrCl 10–30mL/min, or concomitant potent CYP3A4 inhibitors: initially 6.25mg once; max 12.5mg/24hrs. The safety of treating an average of more than 4 migraines over 30 days is not established. <12yrs: Not established.
eletriptan HBr	20mg, 40mg	Relpax	Rx	tabs	≥18yrs: 20mg or 40mg once; max single dose: 40mg. May repeat once after 2hrs; max 80mg/day. The safety of treating an average of more than 3 headaches in a 30-day period has not been established. <18yrs: Not established.
frovatriptan (as succinate)	2.5mg	Frova	Rx	tabs	≥18yrs: 2.5mg with fluids; may repeat once after 2hrs; max 7.5mg/24hrs. The safety of treating an average of more than 4 headaches in a 30-day period has not been established. <18yrs: Not recommended.
naratriptan HCl	1mg, 2.5mg	Amerge	Rx	tabs	≥18yrs: 1mg or 2.5mg with fluids; may repeat once after 4hrs; max 5mg/24hrs. The safety of treating, on average, more than 4 headaches in a 30-day period has not been established. Mild-to-moderate renal/hepatic impairment: initially 1mg; max 2.5mg/24hrs. <18yrs: Not recommended.
rizatriptan (as benzoate)	10mg	Maxalt	Rx	tabs	≥18yrs: Initially 5 or 10mg; may repeat after 2hrs; max 30mg/24hrs. Concomitant propranolol: 5mg; max 15mg/24hrs. The safety of treating, on average, more than 4 headaches in a 30-day period has not been established. <6yrs: Not established. 6–17yrs (<40kg): 5mg; (≥40kg): 10mg. Concomitant propranolol (≥40kg only): max 5mg/24hrs. The efficacy and safety of treating with ≥1 dose/24hrs have not been established.
rizatriptan (as benzoate)	10mg	Maxalt-MLT	Rx	ODT*
sumatriptan	4mg/ 0.5mL, 6mg/ 0.5mL	Imitrex Injection	Rx	SC inj	≥18yrs: 6mg SC (may start at lower dose if 6mg not tolerated). May repeat after 1hr; max two 6mg doses in 24hrs. <18yrs: Not recommended.
	5mg/ spray, 20mg/ spray	Imitrex Nasal Spray	Rx	nasal spray	≥18yrs: 5mg, 10mg, or 20mg once. May repeat once after 2hrs; max 40mg/day. The safety of treating an average of more than 4 headaches in a 30-day period has not been established. <18yrs: Not recommended.
	25mg, 50mg, 100mg	Imitrex Tablets	Rx	tabs	≥18yrs: 25–100mg once, swallow whole with fluids as soon as possible after migraine onset; may repeat dose at intervals of at least 2hrs, max 200mg/day; or single-dose tablets up to 100mg/day if injection has been used. The safety of treating an average of more than 4 headaches in a 30-day period has not been established. <18yrs: Not recommended.
	11mg	Onzetra Xsail	Rx	caps for nasal inh	≥18yrs: 1 nosepiece (11mg) in each nostril (22mg total), using Xsail delivery device. May repeat once after ≥2hrs; max 44mg (4 nosepieces)/day or one dose of Onzetra Xsail and one dose of another sumatriptan product separated by ≥2hrs. The safety of treating an average of more than 4 headaches in a 30-day period has not been established. <18yrs: Not established.
	10mg	Tosymra	Rx	nasal spray	≥18yrs: 10mg as single spray in one nostril. Reevaluate if no response. Max cumulative dose: 30mg in 24hrs with each dose separated by ≥1hr. May also be given ≥1hr after another sumatriptan product. <18yrs: Not recommended.
	3mg/0.5mL	Zembrace Symtouch	Rx	soln for SC inj	≥18yrs: 3mg SC. May repeat after ≥1hr; max 12mg in 24hrs. May also be given ≥1hr after another sumatriptan product. <18yrs: Not recommended.
zolmitriptan	2.5mg+, 5mg	Zomig	Rx	tabs	≥18yrs: Initially 1.25–2.5mg; max recommended single dose: 5mg. If headache returns, may repeat after 2hrs; max 10mg/day. The safety of treating an average of more than 3 headaches in a 30-day period has not been established. Hepatic impairment (moderate to severe): 1.25mg; (severe): max 5mg/day. Concomitant cimetidine: max single dose: 2.5mg, not to exceed 5mg in 24hrs. <18yrs: Not recommended.
	2.5mg, 5mg	Zomig-ZMT	Rx	ODT*
	2.5mg/ spray, 5mg/ spray	Zomig Nasal Spray	Rx	nasal spray	≥12yrs: Initially 2.5mg once; max single dose: 5mg. If headache returns, may repeat once after 2hrs; max 10mg/day. The safety of treating an average of more than 4 headaches in a 30-day period has not been established. Moderate to severe hepatic impairment: not recommended; use other forms. Concomitant cimetidine: max single dose: 2.5mg, not to exceed 5mg in 24hrs. <12yrs: Not established.
Selective 5-HT_1B/1D Receptor Agonist + Non-Steroidal Anti-Inflammatory (NSAID)
sumatriptan succinate/ naproxen sodium	85/ 500mg	Treximet	Rx	tabs	≥12yrs: 1 tab (85/500mg) once; may repeat once after 2hrs; max 2 tabs/day. Mild-to-moderate hepatic impairment: 1 tab (10/60mg)/day. The safety of treating an average of more than 5 migraines in a 30-day period has not been established. <12yrs: Not established. 12–17yrs: 1 tab (10/60mg) once; max 1 tab (85/500mg)/day. The safety of treating an average of more than 2 migraines in a 30-day period has not been established.
Selective 5-HT_1F Receptor Agonist
lasmiditan	50mg, 100mg	Reyvow	CV	tabs	Adults: 50–200mg once as needed; max 1 dose/24hrs. The safety of treating an average of >4 migraines in a 30-day period has not been established. Children: Not established.
PROPHYLAXIS
Antiepileptic Drugs
divalproex sodium	125mg, 250mg, 500mg	Depakote	Rx	del-rel tabs	Adults: Initially 250mg twice daily; usual max 1g/day. Elderly: reduce initial dose and titrate slowly; monitor. Concomitant rufinamide: initiate at a low dose and titrate. Children: Not recommended.
divalproex sodium	250mg, 500mg	Depakote ER	Rx	ext-rel tabs	Adults: 500mg once daily for 1 week, then 1g once daily. Elderly: reduce initial dose and titrate slowly; monitor. Concomitant rufinamide: initiate at a low dose and titrate. Children: Use other forms.
topiramate	15mg, 25mg	Topamax Capsules	Rx	coated beads in caps	≥12yrs: Titrate at 1-wk intervals to target dose of 100mg/day. Initially 25mg once daily in the PM, then 25mg twice daily, then 25mg in the AM and 50mg in the PM, then 50mg twice daily. <12yrs: Not established.
	25mg, 50mg, 100mg, 200mg	Topamax	Rx	tabs
	25mg/mL	Eprontia	Rx	oral soln	Adults: Initially 25mg once daily in the PM, then 25mg twice daily, then 25mg in the AM and 50mg in the PM, then to target dose 50mg twice daily. Titrate at 1wk intervals. Children: Not established.
	25mg, 50mg, 100mg, 200mg	Trokendi XR	Rx	ext-rel caps	≥12yrs: Initially 25mg once daily, increase at 1-wk intervals by increments of 25mg/week to target dose of 100mg once daily. Renal impairment (CrCl <70mL/min): reduce dose by ½. <12yrs: Not established.
Beta-Blockers
propranolol	10mg, 20mg, 40mg, 60mg, 80mg	—	Rx	scored tabs	Adults: Initially 80mg daily in divided doses. Usual range: 160–240mg/day. Discontinue if poor result after 4–6wks. Children: Not recommended.
propranolol	60mg, 80mg, 120mg, 160mg	Inderal LA	Rx	sust-rel caps
timolol	5mg, 10mg+, 20mg+	—	Rx	tabs	Adults: Initially 10mg twice daily. Increase weekly if needed; max 30mg daily in 2 divided doses. Evaluate at 6–8 wks. Children: Not recommended.
Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist
atogepant	10mg, 30mg, 60mg	Qulipta	Rx	tabs	Adults: Episodic migraine: 10mg, 30mg, or 60mg once daily. Chronic migraine: 60mg once daily. Concomitant strong CYP3A4 inhibitors (episodic): 10mg once daily; (chronic): avoid use. Concomitant strong, moderate, or weak CYP3A4 inducers (episodic): 30mg or 60mg once daily; (chronic): avoid use. Concomitant OATP inhibitors (episodic): 10mg or 30mg once daily; (chronic): 30mg once daily. Severe renal impairment, ESRD (episodic): 10mg once daily; (chronic): avoid use. Children: Not established.
eptinezumab-jjmr	100mg/mL	Vyepti	Rx	soln for IV infusion after dilution	Adults: Infuse over 30mins. 100mg every 3mos; some patients may benefit from 300mg every 3mos. Children: Not established.
erenumab-aooe	70mg/mL, 140mg/mL	Aimovig	Rx	soln for SC inj	Adults: 70mg SC once monthly; some patients may benefit from 140mg monthly. Children: Not established.
fremanezumab-vfrm	225mg/1.5mL	Ajovy	Rx	soln for SC inj	Adults: 225mg SC once monthly or 675mg (three 225mg inj) every 3mos. Children: Not established.
galcanezumab-gnlm	100mg/mL, 120mg/mL	Emgality	Rx	soln for SC inj	Adults: Initially 240mg SC loading dose (two 120mg inj), followed by 120mg monthly. Children: Not established.
rimegepant	75mg	Nurtec ODT	Rx	ODT	Adults: Episodic migraine: 75mg every other day. The safety of using more than 18 doses in a 30-day period has not been established. Children: Not established.
NOTES
Key: ODT = orally disintegrating tablets; soln = solution; supp = suppositories; + = scored tablets *contains phenylalanine; †contains caffeine Not an inclusive list of medications, official indications and/or dosages. Please see drug monograph at www.eMPR.com, contact company for full drug labeling and/or consult your healthcare provider. (Rev. 6/2023)

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