What is the emergency medicine treatment for migraine headaches?

From the Guidelines

Emergency treatment for migraines should prioritize NSAIDs, such as ibuprofen or naproxen, and consider triptans, like sumatriptan, for moderate to severe cases, as recommended by the American College of Physicians 1.

Key Considerations

• For mild episodic migraine headache, consider treating with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen 1.
• For moderate to severe acute episodic migraine headache, consider using CGRP antagonists-gepants or ergot alkaloid, and reserve lasmiditan for cases where other treatments are not tolerated or ineffective 1.
• Avoid using opioids or butalbital for the treatment of acute episodic migraine due to the risk of medication overuse headache and other adverse effects 1.

Treatment Approach

• Start treatment as soon as possible after the onset of migraine symptoms to improve efficacy 1.
• Consider using a nonoral triptan and an antiemetic for patients with severe nausea or vomiting 1.
• Educate patients about the control of acute attacks and preventive therapy, and engage them in the formulation of a management plan 1.

Preventive Therapy

• Evaluate patients for the use of preventive therapy if they experience two or more attacks per month that produce disability lasting 3 or more days per month, or if they have contraindications to or failure of acute treatments 1.
• Recommended first-line agents for the prevention of migraine headache include propranolol, timolol, amitriptyline, divalproex sodium, and sodium valproate 1.

From the FDA Drug Label

The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. Dihydroergotamine Mesylate Injection is indicated for the acute treatment of migraine headaches with or without aura and the acute treatment of cluster headache episodes.

Emergency Medicine Treatment for Migraine:

• Sumatriptan (PO): Effective in the acute treatment of migraine headaches, with a significant percentage of patients achieving headache response 2 and 4 hours after treatment 2.
• Dihydroergotamine (IV): Indicated for the acute treatment of migraine headaches with or without aura 3. Key Points:
• Sumatriptan is effective in treating migraine headaches.
• Dihydroergotamine is indicated for acute treatment of migraine headaches.

From the Research

Emergency Medicine Treatment for Migraine

• The primary treatment for moderate-to-severe migraine headaches is triptans, with sumatriptan being the first triptan available in various formulations, including subcutaneous, intranasal, transdermal, oral, and suppository options 4.
• Sumatriptan formulations have different pharmacokinetic, efficacy, and adverse event profiles, with the fastest and most complete migraine relief occurring with subcutaneous dosing 4.
• Metoclopramide, an antiemetic, has also shown pain-relieving effects for migraine and is being investigated as a potential first-line medication for migraine attacks in emergency department settings 5.
• Acetaminophen and nonsteroidal anti-inflammatory drugs are first-line treatments for mild to moderate migraines, while triptans are first-line treatments for moderate to severe migraines 6.
• New classes of acute treatment, including small-molecule calcitonin gene-related peptide receptor antagonists and a 5-HT1F receptor agonist, have expanded available options for migraine treatment 7.
• Triptans, such as sumatriptan, zolmitriptan, naratriptan, rizatriptan, eletriptan, almotriptan, and frovatriptan, display high agonist activity at mainly the serotonin 5-HT1B and 5-HT1D receptor subtypes 8.

Treatment Strategies

• A stratified treatment approach can help ensure that migraine treatment is cost-effective, with patients taking medication early in an attack and using a stepped-care approach 6.
• The choice of treatment depends on the severity of the migraine, with triptans being the mainstay of migraine-specific acute treatment 7.
• Combination therapy, switching within and between classes, and using the maximum allowed dose may improve patient response to acute treatment 7.
• Neuromodulation offers a nonpharmacologic option for acute treatment, with the strongest evidence for remote electrical neuromodulation 7.

Comparison of Triptans

• The therapeutic gain of subcutaneous sumatriptan 6mg (51%) is higher than that of other dosage forms of triptans, including oral sumatriptan 100mg (32%) and oral zolmitriptan 2.5mg (32%) 8.
• The recurrence of headache within 24 hours after an initial successful response occurs in 30 to 40% of sumatriptan-treated patients, with naratriptan having a tendency towards less recurrence 8.
• Rizatriptan tends to produce a quicker onset of headache relief than sumatriptan and zolmitriptan due to its shorter time to maximum concentration (tmax) 8.