Evidence-based migraine treatment: what actually works?

Migraine treatment is best understood as a combination of acute relief and prevention strategies, with effectiveness supported by clinical trials and guideline-based recommendations. Evidence varies in strength, but several treatments consistently stand out.

Top 5 evidence-based migraine treatments

1. Triptans (acute treatment) Triptans (e.g. sumatriptan) are first-line for moderate to severe migraine attacks. Strong evidence shows they are effective in reducing pain and associated symptoms when taken early in an attack. They target serotonin receptors to reduce neurovascular inflammation and pain signalling.

2. NSAIDs (acute treatment) Ibuprofen, naproxen, and aspirin have good evidence for mild to moderate migraine. They are often effective alone or in combination with triptans. Research supports early administration for best outcomes.

3. CGRP-targeting drugs (preventive and acute) Calcitonin gene-related peptide (CGRP) monoclonal antibodies (e.g. erenumab, fremanezumab) and gepants (e.g. rimegepant, ubrogepant) have strong trial evidence for reducing migraine frequency and severity. They are particularly useful in patients who do not respond to traditional therapies.

4. Beta-blockers (preventive treatment) Propranolol and similar beta-blockers have long-standing evidence for reducing migraine frequency. They are widely recommended as first-line preventive options, particularly in patients with frequent attacks.

5. Topiramate (preventive treatment) Topiramate is one of the most effective oral preventive medications. Clinical trials show significant reductions in monthly migraine days, although side effects (such as cognitive slowing or paraesthesia) can limit use.

Key takeaway

The strongest evidence supports a dual approach: rapid acute treatment (triptans or NSAIDs) combined with preventive therapy (beta-blockers, topiramate, or CGRP-based treatments when needed). Treatment choice depends on attack frequency, severity, comorbidities, and individual response.