What is the recommended treatment for acute migraines?

From the Guidelines

The recommended treatment for acute migraines is to start with an NSAID or acetaminophen, and if insufficient pain relief is achieved, add a triptan to the treatment regimen, as recommended by the American College of Physicians in 2025 1. When treating acute migraines, the following options can be considered:

• For mild episodic migraine headache, consider treating with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen 1.
• For moderate to severe acute episodic migraine headache, consider using a triptan and an NSAID or acetaminophen, and if this is not effective, consider using CGRP antagonists-gepants or the ergot alkaloid dihydroergotamine 1.
• If patients do not tolerate or have inadequate response to all other pharmacologic treatments, consider using the ditan lasmiditan 1.
• It is essential to counsel patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy to improve efficacy, and to be aware of medication overuse headache, which is a potential complication of migraine treatment 1. Key points to consider when treating acute migraines include:
• Avoid using opioids or butalbital for the treatment of acute episodic migraine 1.
• Consider using a nonoral triptan and an antiemetic in people having severe nausea or vomiting 1.
• Discuss the adverse effects of pharmacologic treatments during pregnancy and lactation with patients of childbearing potential and those who are pregnant or breastfeeding 1.
• Highlight the importance of lifestyle modifications, including staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, engaging in regular physical activity, managing stress, and pursuing weight loss for those who are overweight or obese 1.

From the FDA Drug Label

Sumatriptan tablets, USP are a serotonin (5-HT1B/1D) receptor agonist (triptan) indicated for acute treatment of migraine with or without aura in adults. Single dose of 25 mg, 50 mg, or 100 mg tablet. A second dose should only be considered if some response to the first dose was observed. Separate doses by at least 2 hours. Maximum dose in a 24-hour period: 200 mg.

The recommended treatment for acute migraines is a single dose of 25 mg, 50 mg, or 100 mg of sumatriptan tablets, with a maximum dose of 200 mg in a 24-hour period 2, 2.

• Key considerations:
  • Use only if a clear diagnosis of migraine headache has been established.
  • Not indicated for the prophylactic therapy of migraine attacks.
  • Not indicated for the treatment of cluster headache.
• Dosage administration:
  • A second dose should only be considered if some response to the first dose was observed.
  • Separate doses by at least 2 hours.

From the Research

Treatment Options for Acute Migraines

• The recommended treatment for acute migraines includes over-the-counter analgesics such as paracetamol (acetaminophen) 3, 4, aspirin 5, and ibuprofen 6.
• These medications can be used alone or in combination with an antiemetic to reduce nausea and vomiting associated with migraines.
• The choice of treatment depends on the severity of the migraine, the presence of contraindications, and the patient's individual response to different medications.

Efficacy of Treatment Options

• Paracetamol 1000 mg alone is an effective treatment for acute migraine headaches, with a number needed to treat (NNT) of 12 for 2-hour pain-free response 3, 4.
• Aspirin 1000 mg is also an effective treatment, with an NNT of 8.1 for 2-hour pain-free response 5.
• Ibuprofen 400 mg is effective, with an NNT of 7.2 for 2-hour pain-free response and 3.2 for 2-hour headache relief 6.
• The addition of an antiemetic, such as metoclopramide, can improve the efficacy of these medications by reducing nausea and vomiting.

Comparison of Treatment Options

• Paracetamol 1000 mg plus metoclopramide 10 mg is not significantly different from oral sumatriptan 100 mg for 2-hour headache relief 3, 4.
• Aspirin 1000 mg is similar to sumatriptan 50 mg or 100 mg in terms of efficacy 5.
• Ibuprofen 400 mg did not differ from rofecoxib 25 mg for 2-hour headache relief, 24-hour headache relief, or use of rescue medication 6.

Considerations for Treatment

• Patient-specific clinical features should guide the selection of an acute medication for an individual patient 7.
• Acute medications can be organized into four treatment strategies: acetaminophen-NSAID, triptan, refractory migraine, and strategies for patients with contraindications to vasoconstricting drugs 7.
• Acetaminophen is the safest acute migraine drug during pregnancy, and acetaminophen with codeine is also an option 7.