What are the best proven methods to prevent and treat migraines?

For a mild to moderate attack, ibuprofen and other anti-inflammatory drugs (NSAIDs) or paracetamol are a good first choice. They work and are inexpensive, but they fall short for severe attacks. Combining an NSAID with a triptan works better than either medication on its own.

Triptans are the best-proven option for a moderate to severe attack. Between 42 and 76% of users experience relief within two hours; 18 to 50% become completely pain-free. They are more effective than NSAIDs, paracetamol, and the older ergot derivatives. One practical rule of thumb: the earlier you take them at the onset of an attack, the better they work.

Newer medications, known as gepants (such as rimegepant) and lasmiditan, work better than a sham treatment but are less effective than most triptans. Their advantage is that they do not constrict blood vessels, making them an option when triptans are medically inadvisable, for example in people with cardiovascular disease. Note that lasmiditan scores the highest for side effects such as dizziness and drowsiness of all the migraine medications compared.

Opioids are not recommended as a standard treatment. The evidence that they help is weak, and the risk of dependence and of headache from medication overuse is real.

For people who have four or more attacks per month, or attacks that are severely disabling, preventive treatment is strongly recommended. The best-supported options are valproate, topiramate, and the beta-blockers propranolol, metoprolol, and timolol. Despite this clear evidence, fewer than 13% of people who qualify for prevention actually use these medications. As a second choice, amitriptyline and venlafaxine are probably effective.

Without medication, relaxation training, biofeedback, and cognitive behavioural therapy are well-supported preventive options with no side effects. They can complement medication or, if you do not want or are unable to use medication, be used on their own. Supplements such as magnesium and riboflavin (vitamin B2) have more limited supporting evidence but are probably somewhat effective. Butterbur also has some evidence for an effect, but only use a certified product free of liver-damaging substances (PA-free).