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Modern migraine treatment includes both acute treatment and preventive therapy. In addition to NSAIDs and triptans, current options include gepants, monoclonal antibodies targeting CGRP or the CGRP receptor, and botulinum toxin therapy . Treatment selection depends on attack frequency and severity, comorbidities, response to previous therapies and patient preferences.
When attacks are infrequent, the main goal is rapid and reliable relief of pain and associated symptoms. When attacks are frequent, prolonged or disabling, preventive treatment should be considered. For chronic migraine, onabotulinumtoxinA treatment using the PREEMPT protocol has a specific role.
Migraine is a primary neurological disorder associated with altered processing of sensory information and activation of the trigeminovascular system. One of the key mediators in migraine is CGRP (calcitonin gene-related peptide) .
CGRP contributes to pain signalling, sensitisation of trigeminal pathways and regulation of vascular tone. Understanding this pathway led to the development of treatments that directly target CGRP signalling: monoclonal antibodies and gepants.
The goal of acute treatment is, whenever possible, to achieve freedom from pain and the most bothersome associated symptoms, restore function quickly and reduce the likelihood of headache recurrence.
For most patients, acute treatment works best when taken early after headache begins, before pain reaches its maximum intensity. The optimal strategy depends on the drug, speed of attack progression, presence of nausea and previous treatment response.
Common options for mild or moderate attacks include:
When an appropriately dosed NSAID taken early in the attack does not provide sufficient relief, migraine-specific therapy may be required.
Triptans remain among the most effective drug classes for acute treatment of moderate or severe migraine.
Examples include:
They act mainly at 5-HT1B/1D receptors and inhibit activation of the trigeminovascular system.
Failure or poor tolerability of one triptan does not necessarily mean that the entire class will be ineffective. Another triptan, a different dose or a different route of administration may work better.
When response to monotherapy is incomplete, a triptan may be combined with an NSAID, for example naproxen.
Gepants are small-molecule CGRP receptor antagonists.
They are used for acute migraine treatment, and some agents are also used for prevention. Unlike triptans, gepants do not cause vasoconstriction.
Depending on the country and local availability, acute-treatment options include:
Rimegepant may be used both for acute treatment and for prevention of episodic migraine.
Gepants are particularly useful when triptans are insufficiently effective, poorly tolerated or undesirable because of vascular contraindications.
The absence of vasoconstriction, however, does not mean that these drugs have no limitations. Drug interactions, renal and hepatic function and comorbidities need to be considered for each individual agent.
Updated prescribing information for some CGRP-targeted treatments also includes post-marketing warnings regarding new or worsening hypertension and Raynaud phenomenon, so the current label for the specific medication should be taken into account.
Lasmiditan is a selective 5-HT1F receptor agonist without clinically significant vasoconstrictive activity. Where available, it can be used for acute migraine treatment, including in some patients for whom triptans are unsuitable.
The main limitations are dizziness, somnolence and effects on driving ability. Driving restrictions in the local prescribing information should be followed.
When nausea or vomiting is prominent, antiemetic treatment and nasal, subcutaneous or other non-oral migraine therapies may be useful, depending on availability.
This is particularly relevant when oral medication cannot be taken or becomes unreliable during an attack.
Frequent use of acute headache medication can contribute to medication-overuse headache (MOH).
Under ICHD-3, when medication is used regularly for more than three months, the diagnostic exposure thresholds include:
For gepants, the traditional MOH thresholds used for triptans or conventional analgesics have not been established. However, a need for very frequent acute treatment should still prompt assessment of total migraine burden and the preventive strategy.
Read more: medication-overuse headache .
The decision to start prevention should not be based only on the absolute number of attacks. Disability, attack duration, effectiveness of acute therapy, frequency of acute medication use and patient preferences also matter.
The joint AAN/AHS 2026 recommendations support offering preventive treatment to patients with 4 or more migraine days per month or 4 or more days with moderate or severe headache per month, as well as to patients with substantial migraine-related disability.
The International Headache Society has also supported a more proactive approach, with discussion of prevention at approximately 2–4 monthly migraine days when the clinical burden justifies treatment.
As migraine days increase, the total disease burden rises and the risk of further progression also becomes more relevant.
Even relatively infrequent attacks may justify prevention when they repeatedly disrupt work, education, family life or social activity.
Other reasons to consider prevention include:
Migraine prevention uses medications from several pharmacological classes, many of which were originally developed for other disorders. They remain effective options in current practice.
Propranolol is one of the best-studied options. Other beta-blockers may also be used depending on guidelines and the clinical situation.
One of the most extensively studied traditional preventive medications for both episodic and chronic migraine.
Amitriptyline and several other medications may be useful in selected patients, particularly when comorbidities influence treatment choice.
Treatment choice depends not only on efficacy, but also on body weight, blood pressure, sleep, psychiatric and other comorbidities, drug interactions, reproductive plans and potential adverse effects.
Preventive treatments that directly target the CGRP pathway include monoclonal antibodies and selected gepants.
The 2024 American Headache Society position statement recognised CGRP-targeted therapy as a first-line option for migraine prevention, alongside traditional preventives, without a mandatory requirement to fail two other preventive classes first.
The AAN/AHS 2026 guideline also confirms the preventive efficacy of several CGRP monoclonal antibodies and atogepant.
Actual prescribing rules, funding and reimbursement, however, vary substantially between countries and healthcare systems.
Subcutaneous agents are usually given monthly or, for some treatment schedules, at longer intervals. Eptinezumab is given intravenously.
These treatments are used for episodic and chronic migraine according to the approved indication of the specific medication.
Advantages include a migraine-specific mechanism, infrequent administration for injectable treatments and generally favourable tolerability.
Possible adverse effects include injection-site reactions, constipation with some agents, and other treatment-specific effects. Current product information should also be considered with regard to blood pressure, Raynaud phenomenon and individual cardiovascular context.
Gepants used for migraine prevention include:
Atogepant is taken daily and is used for migraine prevention in adults according to local approval.
Rimegepant is generally taken every other day when used for prevention and may also be used for acute migraine treatment.
When choosing a gepant, drug interactions, renal and hepatic function, comorbidities and concomitant medications need to be considered.
An inadequate response to one drug does not necessarily mean that the entire CGRP-targeted strategy will fail.
Before changing treatment, it is useful to assess:
In selected patients, switching to another CGRP-targeted therapy may be considered after insufficient response. The optimal sequence of these treatments, however, has not yet been definitively established.
OnabotulinumtoxinA is used for preventive treatment of chronic migraine.
According to ICHD-3, chronic migraine involves headache on at least 15 days per month for more than three months, with at least 8 days per month having migraine features or fulfilling the related ICHD-3 criteria.
The standard protocol uses 155 units across 31 injection sites in seven muscle groups of the head and neck.
Within the PREEMPT paradigm, additional injection sites may increase the total dose to 195 units and the total number of injection sites to 39.
Treatment should not be judged definitively after the first injection cycle.
The AAN/AHS 2026 guideline recommends assessing the effectiveness of onabotulinumtoxinA after approximately 24 weeks of treatment, corresponding to at least two 12-week treatment cycles.
European guidance also recognises that some patients may respond only after the second or third cycle.
Assessment includes:
In clinical practice, some patients with chronic migraine and an incomplete response to a single preventive treatment receive a combination of onabotulinumtoxinA and a CGRP-targeted therapy.
This approach may be considered individually, but it is not a universal treatment strategy for all patients. Availability and reimbursement rules also vary substantially.
Read more: botulinum toxin therapy for chronic migraine .
Treatment response is best evaluated not only by the general impression that migraine is “better” or “worse”, but also through specific measures.
A headache diary can record:
Effective acute treatment should work quickly, reliably and sufficiently well to allow the patient to return to normal activity.
Clinical trials commonly assess pain freedom at 2 hours, freedom from the most bothersome associated symptom, and sustained benefit without early headache recurrence.
A traditional measure of preventive response is approximately a 50% reduction in monthly migraine days.
In chronic or difficult-to-treat migraine, even an improvement of around 30% may be clinically meaningful, particularly when pain intensity, disability and acute medication use also improve.
According to the AAN/AHS 2026 recommendations, most preventive medications should generally be assessed after at least 8–12 weeks at a recommended and tolerated dose.
For onabotulinumtoxinA, the suggested initial evaluation period is 24 weeks.
For CGRP monoclonal antibodies, clinical response is also usually assessed over several months, taking the specific treatment and individual response into account.
| Treatment | Acute treatment | Prevention | Main features |
|---|---|---|---|
| NSAIDs / simple analgesics | Yes | No | Useful for many mild and moderate attacks. Frequency of use should be monitored. |
| Triptans | Yes | No | Highly effective for acute migraine. Vascular contraindications and restrictions apply. |
| Gepants | Yes for selected agents | Yes for selected agents | Do not cause vasoconstriction. Indications, dosing schedules and drug interactions vary between agents. |
| Lasmiditan | Yes | No | No clinically significant vasoconstrictive effect. May cause dizziness and somnolence; driving restrictions are important. |
| Traditional preventive medications | No | Yes | Include, among others, topiramate, beta-blockers, amitriptyline and other treatments. Selection often depends on comorbidities and tolerability. |
| CGRP / CGRP-receptor monoclonal antibodies | No | Yes | Migraine-specific prevention. Infrequent administration and generally favourable tolerability. |
| OnabotulinumtoxinA | No | Yes — for chronic migraine | PREEMPT: 155–195 units, 31–39 sites, every 12 weeks. Initial response is assessed over several months. |
There is no single universal treatment pathway for migraine.
One patient may respond well to a triptan and require no prevention. Another may need a gepant, CGRP-targeted prevention, a traditional preventive medication or onabotulinumtoxinA because of frequent attacks, adverse effects, vascular contraindications or chronic migraine.
Treatment selection takes into account:
This page is intended as medical reference material and does not replace individual medical assessment. Approved indications, availability of individual medications, prescribing restrictions and reimbursement rules vary between countries and may change over time.