Modern migraine treatment is a five-step ladder. Step one is NSAIDs and combination analgesics for mild attacks. Step two is triptans for moderate-to-severe attacks. Step three is the new gepants and ditans for people who cannot tolerate triptans or do not respond. Step four is CGRP monoclonal antibodies for prevention when attacks happen more than four days a month. Step five is neuromodulation and Botox for treatment-resistant chronic migraine. Climbing the ladder in the right order is the difference between years of suffering and real control.
If you have ever felt stuck on a medication that "kind of" works, you are not failing. You are stuck on a rung. The ladder exists for a reason: each step costs more, requires more clinician oversight, and works for a narrower population. Move up only when the step below has been given a fair trial.
Step 1: NSAIDs and combination analgesics (mild attacks)
For mild migraine attacks, especially when caught early:
- Ibuprofen 400 to 800 mg
- Naproxen sodium 500 to 550 mg
- Diclofenac potassium powder (Cambia) 50 mg, the fastest-absorbing NSAID for migraine
- Excedrin Migraine (acetaminophen + aspirin + caffeine)
These work in 30 to 60 minutes if taken at the first sign. Cap NSAID use at 10 to 14 days per month to avoid medication overuse headache. See our full Excedrin Migraine guide.
Step 2: Triptans (moderate to severe attacks)
Triptans were the first migraine-specific drugs. There are seven on the market and they are not interchangeable. If one fails, another may work.
- Sumatriptan (Imitrex): the workhorse, available as pill, nasal spray, and injection
- Rizatriptan (Maxalt): fast oral onset, available as a melt tablet
- Eletriptan (Relpax): longest half-life, best for attacks that come back
- Naratriptan (Amerge): slower but smoother, good for menstrual migraine
- Zolmitriptan (Zomig): nasal spray bypasses gastric stasis
- Frovatriptan (Frova): longest acting, used for menstrual prevention
- Almotriptan (Axert): well tolerated
Do not use triptans if you have coronary artery disease, uncontrolled hypertension, stroke history, or hemiplegic migraine. Cap usage at 10 days per month.
Step 3: Gepants and ditans (newer acute options)
These are the post-triptan generation, launched between 2019 and 2023. They work without constricting blood vessels, which makes them safe for people with cardiovascular risk.
- Ubrogepant (Ubrelvy): oral, take at first sign, repeat in 2 hours if needed
- Rimegepant (Nurtec ODT): oral dissolving tablet, also approved for prevention every other day
- Zavegepant (Zavzpret): nasal spray, peak relief in 15 minutes
- Lasmiditan (Reyvow): a ditan, works on serotonin 1F receptors, causes drowsiness so do not drive for 8 hours
Insurance often requires you to have failed two triptans before approving gepants. Document those failures in your tracker.
Step 4: Preventive medications (4+ attack days per month)
If you are losing more than four days a month, prevention is no longer optional. Options range from oldest to newest:
- Beta blockers (propranolol, metoprolol): cheap, effective, evidence going back 50 years
- Topiramate (Topamax): effective but side effects include word-finding trouble
- Amitriptyline: especially useful when migraine overlaps with tension or insomnia
- Candesartan: an ARB with strong evidence, often overlooked
- CGRP monoclonal antibodies: erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), eptinezumab (Vyepti). Monthly injection or IV infusion. See CGRP inhibitors what to know.
- Atogepant (Qulipta) and rimegepant (Nurtec): oral gepants approved for prevention
Give any preventive 8 to 12 weeks before deciding it has failed.
Step 5: Neuromodulation, Botox, and procedures
For chronic migraine (15+ headache days per month, 8+ migraine days):
- OnabotulinumtoxinA (Botox): 31 injections every 12 weeks, established protocol
- Cefaly (external trigeminal nerve stimulator): FDA-approved, daily 20-minute sessions
- Nerivio (remote electrical neuromodulation): arm-worn device for acute treatment
- gammaCore (non-invasive vagus nerve stimulator)
- Occipital nerve blocks: in-office injection, lasts weeks to months
See digital therapeutics and neuromodulation.
How to climb the ladder
Move up only when you have given the current step a real trial: correct dose, taken early, used on 3 to 5 separate attacks. Track every attempt, including what dose, what time, and what relief you got. Your neurologist needs that data to justify each step to your insurer.
Sources
- CGRP-targeting therapies are a first-line option for the prevention of migraine: an American Headache Society position statement update — Headache, 2024;64(4):333-341
- The American Headache Society consensus statement: update on integrating new migraine treatments into clinical practice — Ailani, Burch & Robbins, Headache, 2021;61(7):1021-1039
- Pathophysiology, prevention, and treatment of medication overuse headache — Diener et al., Lancet Neurology, 2019;18(9):891-902
- Effect of ubrogepant vs placebo on pain and the most bothersome associated symptom in the acute treatment of migraine (ACHIEVE II) — Lipton et al., JAMA, 2019;322(19):1887-1898
- A controlled trial of erenumab for episodic migraine — Goadsby et al., New England Journal of Medicine, 2017;377(22):2123-2132
