What is the recommended treatment for acute migraine attacks?

From the Guidelines

The most effective abortive treatment for migraines involves the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or diclofenac potassium as first-line medication, with triptans as second-line medication, as recommended by the most recent study 1. When considering abortive treatment for migraines, it's essential to prioritize medications that can be taken at the first sign of symptoms to maximize their effectiveness.

• The first-line treatments include NSAIDs such as ibuprofen (400-600mg) or diclofenac potassium, which work by reducing inflammation and pain by inhibiting prostaglandin synthesis.
• For moderate to severe migraines, triptans are often more effective, with options like sumatriptan (50-100mg oral, 6mg subcutaneous, or 20mg nasal spray) being commonly prescribed, as they constrict blood vessels and block pain pathways in the brain 1.
• Additionally, combining triptans with fast-acting NSAIDs can help avert recurrent relapse, and prokinetic antiemetics like domperidone or metoclopramide can be used as adjunct oral medications for nausea and/or vomiting 1.
• It's crucial to advise patients to use acute medications early in the headache phase of the attack and to limit frequent, repeated use to avoid the development of medication overuse headaches (MOH) 1.
• Other options like ditans and gepants can be considered as third-line medications, while oral ergot alkaloids, opioids, and barbiturates should be avoided due to their potential risks and side effects 1.

From the FDA Drug Label

The maximum recommended single dose is 40 mg. In controlled clinical trials, single doses of 20 mg and 40 mg were effective for the acute treatment of migraine in adults. The percentage of patients achieving headache response 2 hours after treatment was significantly greater among patients receiving eletriptan hydrobromide at all doses compared to those who received placebo.

The recommended abortive treatment for migraines is a single dose of 20 mg or 40 mg of eletriptan. If the migraine has not resolved by 2 hours after taking the medication, or returns after transient improvement, a second dose may be administered at least 2 hours after the first dose, with a maximum daily dose not exceeding 80 mg 2.

From the Research

Abortive Treatment for Migraines

The recommended treatment for acute migraine attacks includes abortive medications such as sumatriptan, which belongs to the triptan family.

• Sumatriptan is available for administration by four different routes: oral, subcutaneous, intranasal, and rectal 3.
• The most effective dose of sumatriptan for each route of administration for the outcome of headache relief at two hours was oral 100 mg, subcutaneous 6 mg, intranasal 20 mg, and rectal 25 mg 3.
• Subcutaneous administration was the most effective, with pain reduced from moderate or severe to none by two hours in almost 6 in 10 people (59%) taking 6 mg sumatriptan, compared with approximately 1 in 7 (15%) taking placebo 3.
• Oral sumatriptan is effective as an abortive treatment for migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events relative to placebo 4.
• Intranasal sumatriptan is effective as an abortive treatment for acute migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events compared with placebo 5.
• Subcutaneous sumatriptan is effective as an abortive treatment for acute migraine attacks, quickly relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events 6.

Efficacy of Sumatriptan

The efficacy of sumatriptan varies depending on the route of administration and the dose used.

• The NNTs for sumatriptan 50 mg versus placebo were 6.1,7.5, and 4.0 for pain-free at two hours and headache relief at one and two hours, respectively 4.
• The NNTs for sumatriptan 10 mg versus placebo were 7.3,7.4, and 5.5 for pain-free at two hours, and headache relief at one and two hours, respectively 5.
• The NNTs for sumatriptan 6 mg versus placebo were 2.9,2.3,2.2, and 2.1 for pain-free at one and two hours, and headache relief at one and two hours, respectively 6.

Adverse Events

Adverse events associated with sumatriptan are generally mild and transient, but can be more common with higher doses and certain routes of administration.

• Adverse events were more common with subcutaneously administered sumatriptan and higher doses of oral and intranasal sumatriptan than with other dose and route combinations 3.
• The most common adverse events associated with sumatriptan include chest pain, nausea, photophobia, and phonophobia 4, 7, 5, 6.