What are the treatment options for acute migraine?

From the Guidelines

Treatment of acute migraine should prioritize nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen for mild episodes, and triptans or CGRP antagonists for moderate to severe episodes, as recommended by the American College of Physicians guideline from 2025 1. When considering treatment options for acute migraine, several factors should be taken into account, including the severity of the migraine, patient preferences, and potential side effects.

• For mild episodic migraine headache, consider treating with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen, as these options are often effective and have a favorable side effect profile 1.
• For moderate to severe acute episodic migraine headache, consider using triptans, such as sumatriptan or rizatriptan, or CGRP antagonists, such as rimegepant or ubrogepant, as these options have been shown to be effective in reducing migraine symptoms 1.
• Additionally, consider using a nonoral triptan and an antiemetic in people having severe nausea or vomiting, as this can help to alleviate associated symptoms 1.
• It is also important 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 the potential for medication overuse headache, which can occur when acute medications are used more than 15 days per month 1.
• In people of childbearing potential and in those who are pregnant or breastfeeding, it is essential to discuss the potential adverse effects of pharmacologic treatments during pregnancy and lactation, and to consider alternative treatment options when necessary 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. In all 3 trials, the percentage of patients achieving headache response 2 and 4 hours after treatment was significantly greater among patients receiving sumatriptan tablets at all doses compared with those who received placebo

Acute Migraine Treatment Options:

• Sumatriptan (PO): effective in the acute treatment of migraine headaches, with a significant percentage of patients achieving headache response 2 and 4 hours after treatment 2
• Eletriptan (PO): although the label does not directly discuss its efficacy in acute migraine treatment, it is a 5-HT1 agonist, which is a class of drugs used to treat migraines 3

Key Considerations:

• Sumatriptan is effective for acute migraine treatment
• Eletriptan's label does not provide direct evidence for its use in acute migraine treatment, but it is a 5-HT1 agonist, which may be used for migraine treatment in certain cases.

From the Research

Treatment Options for Acute Migraine

• The primary treatment options for acute migraine include triptans, nonsteroidal anti-inflammatory drugs (NSAIDs), and antiemetic drugs 4, 5, 6, 7.
• Triptans, such as sumatriptan, are effective in relieving pain, nausea, photophobia, and phonophobia, but are associated with increased adverse events 4, 6, 8.
• NSAIDs, such as ibuprofen, naproxen, and diclofenac, are also effective in treating acute migraine attacks, and are often used in combination with triptans 5, 7.
• Antiemetic drugs, such as prochlorperazine, can be used to alleviate nausea and vomiting associated with migraine attacks 5, 7.

Route of Administration

• Sumatriptan can be administered through various routes, including oral, subcutaneous, intranasal, and rectal, each with different efficacy and tolerability profiles 8.
• Subcutaneous administration is the most effective route, with a high rate of pain relief, but is also associated with higher levels of adverse events 8.
• Oral administration is the most commonly used route, with a lower rate of pain relief compared to subcutaneous administration, but is still effective in relieving migraine symptoms 4, 6, 8.

Dosing and Efficacy

• The efficacy of sumatriptan varies depending on the dose and route of administration, with higher doses generally providing greater pain relief, but also increasing the risk of adverse events 4, 6, 8.
• The most effective dose of sumatriptan for each route of administration is oral 100 mg, subcutaneous 6 mg, intranasal 20 mg, and rectal 25 mg, with corresponding numbers needed to treat (NNTs) for headache relief at two hours 8.
• Early treatment, when pain is mild, is more effective than waiting until pain is moderate or severe, and can reduce the risk of adverse events 6, 8.

Special Considerations

• Acetaminophen is the safest acute migraine drug during pregnancy, and acetaminophen with codeine is also an option 5.
• Sumatriptan may be an option during pregnancy for selected patients, and is compatible with breast-feeding 5.
• Opioids and combination analgesics containing opioids should not be used routinely for acute migraine treatment due to the risk of serious adverse events 5, 7.