What are the treatment options for migraine in Emergency Department (ED)?

From the Guidelines

For migraine treatment, I recommend starting with an NSAID or acetaminophen, and if insufficient, adding a triptan, as this approach has been shown to be effective in achieving sufficient pain relief. When selecting a specific NSAID, such as aspirin, celecoxib, diclofenac, ibuprofen, or naproxen, or a triptan, such as almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan, the choice should be based on individualized decision making, taking into consideration patient preferences and factors such as route of administration and cost 1. Some key points to consider in migraine treatment include:

• Ensuring the appropriate dosage of NSAIDs or acetaminophen is used, and considering increasing the dosage without exceeding the recommended maximum daily dose if patients do not achieve sufficient pain relief 1
• Adding a triptan to an NSAID, or to acetaminophen when NSAIDs are contraindicated or not tolerated, if patients do not have sufficient pain relief with an adequate dose of an NSAID or acetaminophen 1
• Considering treating mild episodic migraine headache with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen 1
• Considering using CGRP antagonists-gepants, such as rimegepant, ubrogepant, or zavegepant, or ergot alkaloid, such as dihydroergotamine, to treat moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen 1
• Avoiding the use of opioids or butalbital for the treatment of acute episodic migraine, due to the risk of medication overuse headache 1.

From the FDA Drug Label

CLINICAL TRIALS Migraine In US controlled clinical trials enrolling more than 1,000 patients during migraine attacks who were experiencing moderate or severe pain and 1 or more of the symptoms enumerated in Table 2, onset of relief began as early as 10 minutes following a 6-mg IMITREX Injection The efficacy of IMITREX Injection is unaffected by whether or not migraine is associated with aura, duration of attack, gender or age of the patient, or concomitant use of common migraine prophylactic drugs (e.g., beta-blockers).

Migraine Treatment in ED:

• The FDA-approved drug label for sumatriptan (IV) indicates that it is effective for the treatment of migraine attacks, with onset of relief as early as 10 minutes following a 6-mg injection 2.
• The efficacy of sumatriptan is unaffected by the presence of aura, duration of attack, gender, age, or concomitant use of common migraine prophylactic drugs.
• However, it is crucial to note that sumatriptan is contraindicated in patients with certain conditions, such as uncontrolled hypertension, and should be used with caution in patients with controlled hypertension 2.

From the Research

Migraine Treatment in the Emergency Department

• Migraine is a common reason for visits to the emergency room, with attacks often being more severe and refractory to home rescue medication 3.
• First-line treatments for migraine in the emergency department include metoclopramide, prochlorperazine, and sumatriptan, but these may fail to provide sufficient relief in up to one-third of treated patients 4.
• Second-line interventions for migraine in the emergency department may include injectable non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, as well as dihydroergotamine and valproic acid, which have some data supporting efficacy 4.
• Greater occipital nerve blocks (GONBs) have also been shown to be efficacious in the treatment of migraine in the emergency department 4.

Comparison of Treatments

• A study comparing metoclopramide and sumatriptan for the treatment of migraine in the emergency department found that metoclopramide may be non-inferior to sumatriptan as a first-line medication for migraine attacks in ED settings 5.
• The combination of sumatriptan and naproxen has been shown to be effective in the acute treatment of migraine headaches, with a greater effect than either monotherapy alone 6.
• Treating migraine early, when pain is still mild, has been shown to be significantly better than treating once pain is moderate or severe 6.

Treatment Options

• Triptans, ergot derivatives, and nonsteroidal anti-inflammatory drugs have historically been the main acute treatments for migraine, but new classes of acute treatment, including small-molecule calcitonin gene-related peptide receptor antagonists and a 5-HT1F receptor agonist, are expanding available options 7.
• Neuromodulation offers a nonpharmacologic option for acute treatment, with the strongest evidence for remote electrical neuromodulation 7.
• There is no one-size-fits-all acute treatment, and multiple treatment trials may be necessary to determine the optimal regimen for patients 7.