What is the initial treatment for migraines in an urgent care setting?

From the Guidelines

The initial treatment for migraines in an urgent care setting should prioritize triptans, such as sumatriptan, due to their efficacy in relieving migraine symptoms, as supported by the most recent evidence 1. When managing migraines in an urgent care setting, it's crucial to consider the severity of symptoms and the presence of nausea or vomiting.

• For patients presenting early with nausea or vomiting, a nonoral route of administration is recommended, such as subcutaneous sumatriptan or DHE nasal spray, as suggested by 1.
• Antiemetics should be considered to treat nausea, regardless of the presence of vomiting, as they can significantly improve patient comfort and medication absorption.
• The selection of acute therapy should be individualized, with the goal of providing the best personal outcome for each patient, as emphasized in 1. Key considerations in the urgent care setting include:
• Providing a quiet, dimly lit environment to minimize exacerbating factors
• Administering intravenous fluids for hydration, especially if the patient has been vomiting
• Avoiding medications with high risk of abuse or sedation side effects, unless necessary and with appropriate precautions
• Evaluating the need for preventive therapy in patients with frequent or severe migraines, as outlined in 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION 2. 1 Dosing Information The recommended dose of sumatriptan tablets is 25 mg, 50 mg, or 100 mg. The initial treatment for migraines in an urgent care setting is sumatriptan tablets with a recommended dose of 25 mg, 50 mg, or 100 mg 2.

• The dose of 50 mg and 100 mg may provide a greater effect than the 25 mg dose.
• A second dose may be administered at least 2 hours after the first dose if the migraine has not resolved.
• The maximum daily dose is 200 mg in a 24-hour period.

From the Research

Initial Treatment for Migraines in Urgent Care

• The initial treatment for migraines in an urgent care setting may involve the use of medications such as triptans, nonsteroidal anti-inflammatory drugs, and anti-emetics 3, 4, 5.
• According to a study published in 2020, only 11.1% of patients who did not have a record of previous triptan use were given a triptan prescription at the urgent care visit 3.
• Another study published in 2024 found that triptans are still the mainstay of migraine-specific acute treatment, but new classes of acute treatment, including the small-molecule calcitonin gene-related peptide receptor antagonists and a 5-HT1F receptor agonist, are also available 4.
• Intravenous metoclopramide may be given to some patients, but its use is not common, with only 12.3% of patients receiving it in one study 3.
• Anti-emetics may also be prescribed, especially for patients with nausea or vomiting, with 46.2% of patients receiving an anti-emetic at the visit and 33.3% being given an anti-emetic prescription 3.

Medication Options

• Triptans, such as sumatriptan, zolmitriptan, and rizatriptan, are effective in the acute treatment of migraine and are available in various formulations, including oral tablets, subcutaneous injections, and nasal sprays 5.
• Nonsteroidal anti-inflammatory drugs, such as ibuprofen and naproxen, may also be used to treat migraine attacks 6, 4.
• Anti-emetics, such as metoclopramide, may be prescribed to help manage nausea and vomiting associated with migraine 3.

Treatment Approach

• The treatment approach for migraines in urgent care settings may vary depending on the patient's specific needs and medical history 3, 4.
• A study published in 2018 found that standardized headache protocols may decrease opioid use and provide significant pain relief for patients 7.
• Another study published in 2020 found that having migraine-specific prescriptions, such as triptans and anti-emetics, may improve self-treatment at home should a migraine attack recur 3.