What are the treatment options for acute migraine?

From the Guidelines

Treatment for acute migraine should start with over-the-counter pain relievers like ibuprofen, naproxen sodium, or aspirin, and for more severe cases, prescription triptans such as sumatriptan, rizatriptan, or zolmitriptan should be considered. According to the American College of Physicians guideline 1, for mild episodic migraine headache, treatment with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen is recommended.

Key Treatment Options

• Over-the-counter pain relievers: ibuprofen (400-600mg), naproxen sodium (500-550mg), or aspirin (900-1000mg)
• Prescription triptans: sumatriptan (50-100mg orally, 6mg subcutaneously, or 20mg nasal spray), rizatriptan (10mg), or zolmitriptan (2.5-5mg)
• Anti-nausea medications: metoclopramide (10mg) or prochlorperazine (10mg)
• For status migrainous: dihydroergotamine (DHE 45) at 1mg IV or IM, or a course of dexamethasone (10mg IV followed by 4mg every 6 hours)

Additional Considerations

• CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) may be considered 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.
• The ditan lasmiditan may be used 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 1.
• Opioids or butalbital should not be used for the treatment of acute episodic migraine 1.
• Patients should be aware of medication overuse headache, which is a potential complication of migraine treatment, and lifestyle modifications such as 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 should be highlighted 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. Rizatriptan benzoate is used for the acute treatment of migraine attacks. The following drugs are used to stop acute migraine:

• Sumatriptan (PO): used for the acute treatment of migraine headaches 2
• Rizatriptan (PO): used for the acute treatment of migraine attacks 3 Note: Sumatriptan (IN) is also mentioned, but the question asks for drugs used to stop acute migraine, and the text does not explicitly state that sumatriptan (IN) is used for this purpose 4

From the Research

Treatment Options for Acute Migraine

The following are some of the treatment options for acute migraine:

• Analgesics like aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating migraine attacks 5
• Triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) are highly effective in improving headache as well as nausea, photo- and phonophobia 5, 6
• Acetaminophen is suitable for mild to moderate migraine attacks and remains the first choice for children and pregnant women 6, 7
• Antiemetic drugs can be added as necessary to alleviate nausea and vomiting 6, 7
• Ergotamine and dihydroergotamine (DHE) are also suitable for selected patients 5, 6
• Combination analgesics containing opioids should not be used routinely 6
• Gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, such as rimegepant or ubrogepant, can eliminate headache symptoms for 2 hours in 20% of patients 8
• A 5-HT1F agonist, lasmiditan, is also available for acute migraine treatment and appears safe in patients with cardiovascular risk factors 8

Stratified Care Approach

A stratified care approach can be used to guide the selection of an acute medication for an individual patient:

• For mild to moderate migraine attacks, oral NSAIDs are the first choice; with oral aspirin, combination analgesics, intravenous/intramuscular NSAIDs as alternatives 7
• For moderate to severe attacks, oral or nasal spray triptans and ergotamine/caffeine compounds are recommended and should be administered in the early stage of migraine attacks 7
• A combination of a triptan and a NSAID yielded a better efficacy compared with either therapy alone 7