From the Guidelines
Opioids should not be used for the treatment of acute episodic migraine. The most recent and highest quality study, published in 2025 in the Annals of Internal Medicine 1, provides clear guidance on the pharmacologic treatments of acute episodic migraine headache in outpatient settings. According to this study, the recommended treatments for acute migraine include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, celecoxib, diclofenac, ibuprofen, or naproxen
- Acetaminophen
- Triptans, such as almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan
- CGRP antagonists-gepants, such as rimegepant, ubrogepant, or zavegepant
- Ergot alkaloid, dihydroergotamine
- The ditan lasmiditan, for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to all other pharmacologic treatments.
The study explicitly states that opioids or butalbital should not be used for the treatment of acute episodic migraine 1. This recommendation prioritizes the reduction of morbidity, mortality, and improvement of quality of life for patients with acute migraine. Instead, healthcare providers should consider individualized treatment approaches, taking into account patient preferences and factors such as route of administration and cost.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Recommended Treatments for Acute Migraine
- The primary goals of acute migraine therapy are to reduce attack duration and severity 2
- Current evidence-based therapies for acute migraine attacks include:
- Acetaminophen
- Four nonsteroidal anti-inflammatory drugs (NSAIDs): ibuprofen, naproxen, diclofenac, and acetylsalicylic acid
- Seven triptans: sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, and naratriptan
- Dihydroergotamine (DHE)
- Non-opioid combination analgesics
- Anti-emetics 3, 2, 4
- Opioids and combination analgesics containing opioids should not be used routinely for acute migraine treatment due to limited evidence and potential for serious adverse events 3, 5, 4
- Treatment strategies can be organized into four categories:
- Acetaminophen-NSAID strategy for mild to moderate attacks
- Triptan strategy for severe attacks or moderate attacks that do not respond to NSAIDs
- Refractory migraine strategies for patients who do not respond to NSAIDs or triptans alone
- Strategies for patients with contraindications to vasoconstricting drugs 3
Use of Opioids for Acute Migraine
- The evidence for using opioids to treat acute migraine is limited or insufficient 5
- Opiates are not recommended for acute migraine treatment due to serious adverse events 4
- The use of acute treatment, including opioids, should be limited to a maximum of ten days a month to prevent medication-overuse headache 4
Other Treatment Options
- New classes of acute treatment, including calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan), are available and have not been associated with vasospasm or increased cardiovascular risk 6
- Neuromodulation offers a nonpharmacologic option for acute treatment, with the strongest evidence for remote electrical neuromodulation 5, 6