From the Guidelines
Atypical migraines can be effectively treated with a combination of pharmacologic and non-pharmacologic approaches, prioritizing the use of NSAIDs, triptans, and CGRP antagonists as first-line options. When considering treatment for atypical migraines, it's essential to evaluate the patient's specific symptoms, comorbidities, and previous treatment responses. The most recent and highest quality study 1 recommends the following treatment approaches:
- Consider treating mild episodic migraine headache with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen.
- For moderate to severe acute episodic migraine headache, consider using CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) in nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen.
- Consider using the ditan lasmiditan to treat 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 this guideline. Some key points to consider when treating atypical migraines include:
- Counseling patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy (such as a triptan with an NSAID or acetaminophen) to improve efficacy.
- Being aware of medication overuse headache, which is a potential complication of migraine treatment.
- Individualizing treatment based on the specific atypical features, comorbidities, and previous treatment responses, with close monitoring for effectiveness and side effects.
From the FDA Drug Label
The use of sumatriptan tablets is contraindicated in patients with CAD and those with Prinzmetal’s variant angina. Before treating headaches in patients not previously diagnosed as migraineurs, and in migraineurs who present with atypical symptoms, exclude other potentially serious neurological conditions.
Atypical Migraine Treatment:
- Sumatriptan is not recommended for patients with atypical migraine symptoms without first excluding other potentially serious neurological conditions 2.
- The drug label does not provide specific treatment recommendations for atypical migraines, but it emphasizes the importance of diagnosing and treating migraines accurately to avoid misdiagnosis and inappropriate treatment 2.
- Patients with atypical symptoms should be evaluated for other conditions before being treated with sumatriptan 2.
From the Research
Atypical Migraine Treatment Options
- Atypical migraine treatment may involve various pharmacological approaches, including analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, and ergotamines 3.
- New classes of acute treatment, such as small-molecule calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan), have been developed and offer alternative options for patients who cannot use traditional treatments due to cardiovascular risk or other contraindications 4.
- The choice of acute migraine medication depends on various clinical features, including usual headache intensity, rapidity of pain intensity increase, nausea, vomiting, degree of disability, and patient response to previously used medications 5.
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
- Triptan strategy for patients with severe attacks and for attacks not responding to strategy one
- Refractory attack strategy
- Strategy for patients with contraindications to vasoconstricting drugs 5
- Effective treatment of migraine requires the clinician to assess the patient, make an accurate diagnosis, and then offer appropriate therapy based on the patient's medical history, comorbidities, and preferences, as well as published clinical evidence 6.
Recent Developments
- The acute treatment landscape for migraine has recently expanded to include neuromodulation devices, calcitonin gene-related peptide receptor antagonists, and a serotonin (5-HT1F) receptor agonist 6.
- Preventive treatments, such as antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, can reduce migraine frequency by 1 to 3 days per month relative to placebo 7.
- Gepants and lasmiditan are new acute treatment options that can eliminate headache symptoms for 2 hours in some patients, but may have adverse effects such as nausea and dry mouth 7.