From the Guidelines
Acute migraine treatment should start with a combination of an NSAID and acetaminophen, or a triptan added to an NSAID or acetaminophen if the initial treatment is insufficient, as recommended by the American College of Physicians guideline published in 2025 1. The choice of a specific NSAID, such as aspirin, celecoxib, diclofenac, ibuprofen, or naproxen, or triptan, including 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. Key considerations for acute migraine treatment include:
- Treating mild episodic migraine headache with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen 1
- Using CGRP antagonists-gepants, such as rimegepant, ubrogepant, or zavegepant, or ergot alkaloid, such as dihydroergotamine, for 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 1
- Considering the use of a nonoral triptan and an antiemetic in people having severe nausea or vomiting 1
- Counseling patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy to improve efficacy 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 The results from the 3 controlled clinical trials are summarized in Table 2. Table 2 Percentage of Patients With Headache Response (Mild or No Headache) 2 and 4 Hours Following Treatment Sumatriptan Tablets 25 mg 2 hr 4 hr Sumatriptan Tablets 50 mg 2 hr 4 hr Sumatriptan Tablets 100 mg 2 hr 4 hr Placebo 2 hr 4 hr
Acute Migraine Treatment with Sumatriptan:
- Sumatriptan tablets are effective in the acute treatment of migraine headaches.
- 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.
- Doses of 25,50, and 100 mg were compared with placebo, and all doses showed significant efficacy.
- There were no statistically significant differences between the 50 mg and 100 mg dose groups in any trial 2.
From the Research
Acute Migraine Treatment Options
- Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and triptans have good evidence for efficacy in treating acute migraine attacks 3, 4, 5
- NSAID-triptan combinations, dihydroergotamine, non-opioid combination analgesics, and anti-emetics are additional evidence-based options for acute migraine treatment 3, 4
- Opioid-containing combination analgesics may be helpful in specific patients, but should not be used routinely 3, 4
Treatment Strategies
- Available acute medications can be organized into four treatment strategies:
- Strategy one: acetaminophen and/or NSAIDs for attacks of mild to moderate severity 3, 4
- Triptan strategy for patients with severe attacks and for attacks not responding to strategy one 3, 4
- Refractory attack strategy for patients who do not respond well to NSAIDs or triptans alone 3, 4
- Strategy for patients with contraindications to vasoconstricting drugs, including use of NSAIDs, combination analgesics, and dopamine antagonists 3, 4
Combination Therapies
- Combining triptans with NSAIDs has demonstrated better efficacy in treating acute migraine attacks 6, 7
- The fixed combination of sumatriptan and naproxen sodium offers improved 2-hour and 24-hour benefits over monotherapy with each option 6, 7