What are the treatment options for outpatient management of acute migraine headache?

From the Guidelines

Outpatient treatment of acute migraine should start with ensuring the appropriate dosage of NSAIDs or acetaminophen, and consider adding a triptan if sufficient pain relief is not achieved, as recommended by the American College of Physicians guideline 1. When treating acute migraine in an outpatient setting, the following key points should be considered:

• Ensuring the appropriate dosage of NSAIDs or acetaminophen is crucial, and increasing the dosage without exceeding the recommended maximum daily dose may be necessary for patients who do not achieve sufficient pain relief 1.
• If patients do not respond to an adequate dose of NSAIDs or acetaminophen, adding a triptan to an NSAID, or to acetaminophen when NSAIDs are contraindicated or not tolerated, is a recommended approach 1.
• The choice of a specific NSAID (such as aspirin, celecoxib, diclofenac, ibuprofen, or naproxen) or triptan (such as almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan) should be based on individualized decision making, taking into consideration patient preferences and factors such as route of administration and cost 1.
• For mild episodic migraine headache, treatment with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen may be considered 1.
• In cases where patients do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen, CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) may be considered for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults 1.
• Additionally, the ditan lasmiditan may be considered for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to all other pharmacologic treatments included in the guideline 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. In all 3 trials, the percentage of patients achieving headache response 2 and 4 hours after treatment was significantly greater among patients receiving sumatriptan tablets at all doses compared with those who received placebo

Outpatient treatment of acute migraine can be achieved with sumatriptan (PO), as it has been shown to be effective in reducing headache severity from moderate or severe pain to mild or no pain in clinical trials 2.

• The medication has been tested in 3 randomized, double-blind, placebo-controlled trials.
• Doses of 25,50, and 100 mg were compared with placebo, and all doses showed a significant improvement in headache response at 2 and 4 hours after treatment.
• There were no statistically significant differences between the 50 mg and 100 mg dose groups in any trial.

From the Research

Outpatient Treatment of Acute Migraine

• The treatment of acute migraine can be approached through various strategies, including the use of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, and antiemetics 3, 4, 5, 6, 7.
• Acetaminophen and NSAIDs are considered first-line treatments for mild to moderate migraines, while triptans are first-line treatments for moderate to severe migraines 3, 5, 6, 7.
• The combination of a triptan and an NSAID has been shown to be more effective than either therapy alone 7.
• Antiemetics can be used as a supplement to alleviate nausea and vomiting associated with migraine attacks 3, 4, 5, 7.
• The treatment approach should be individualized based on the pattern and severity of attacks, as well as the patient's clinical features and medical history 3, 5, 6.
• Stratified care is recommended, where patients with mild to moderate migraine attacks are treated with oral NSAIDs, and those with moderate to severe attacks are treated with oral or nasal spray triptans and ergotamine/caffeine compounds 7.
• Acetaminophen is considered a safe option for acute migraine treatment during pregnancy and is also suitable for children and pregnant women 5, 7.
• Opiates are not recommended for acute migraine treatment due to the risk of serious adverse events 7.
• The use of acute treatment should be limited to a maximum of ten days a month to prevent medication-overuse headache 7.

Treatment Options

• Acetaminophen: effective for mild to moderate migraine attacks and considered safe during pregnancy 4, 5, 7.
• NSAIDs: effective for mild to moderate migraine attacks and considered first-line treatment 3, 5, 6, 7.
• Triptans: effective for moderate to severe migraine attacks and considered first-line treatment 3, 5, 6, 7.
• Antiemetics: effective for alleviating nausea and vomiting associated with migraine attacks 3, 4, 5, 7.
• Ergotamine/caffeine compounds: effective for moderate to severe migraine attacks 7.
• Dihydroergotamine (DHE): suitable for selected patients and considered effective for acute migraine treatment 3, 5.

Special Considerations

• Pregnancy: acetaminophen is considered a safe option for acute migraine treatment during pregnancy 5, 7.
• Children: acetaminophen is considered a suitable option for acute migraine treatment in children 7.
• Medication-overuse headache: the use of acute treatment should be limited to a maximum of ten days a month to prevent medication-overuse headache 7.