From the Guidelines
For the treatment of episodic migraines, consider starting with an NSAID, acetaminophen, or a combination of both for mild attacks, and reserve triptans, CGRP antagonists, or ergot alkaloids for moderate to severe attacks that do not respond to initial therapy. When choosing a specific treatment, individualized decision-making is crucial, taking into account patient preferences, such as route of administration and cost 1. Key considerations include:
- For mild episodic migraine headache, NSAIDs (aspirin, celecoxib, diclofenac, ibuprofen, or naproxen), acetaminophen, or the combination of an NSAID and acetaminophen can be effective 1.
- For moderate to severe acute episodic migraine headache, CGRP antagonists (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) may be considered, especially in nonpregnant outpatient adults who do not tolerate or have an inadequate response to combination therapy of a triptan and an NSAID or acetaminophen 1.
- The use of opioids or butalbital for the treatment of acute episodic migraine is not recommended due to potential adverse effects and the risk of medication overuse headache 1.
- Nonoral triptans and antiemetics should be considered for patients with severe nausea or vomiting 1.
- Preventive medications may be warranted if episodic migraines occur frequently or if treatment does not provide an adequate response, with options including propranolol, topiramate, amitriptyline, valproate, and CGRP monoclonal antibodies 1. It is essential to counsel patients on the importance of starting treatment as soon as possible after the onset of migraine symptoms and to be aware of the potential for medication overuse headache 1.
From the FDA Drug Label
The efficacy of rizatriptan benzoate orally disintegrating tablets in pediatric patients 6 to 17 years was evaluated in a multicenter, randomized, double-blind, placebo-controlled, parallel group clinical trial (Study 7) Patients had to have at least a 6 month history of migraine attacks (with or without aura) usually lasting 3 hours or more (when untreated). The patient population was historically non-responsive to NSAIDs and acetaminophen therapy. Patients were instructed to treat a single migraine attack with headache pain of moderate to severe intensity. Dihydroergotamine Mesylate Injection is indicated for the acute treatment of migraine headaches with or without aura
Treatment Options for Episodic Migraines:
- Rizatriptan benzoate orally disintegrating tablets
- Dihydroergotamine Mesylate Injection Key Considerations:
- Efficacy of rizatriptan benzoate was evaluated in clinical trials, including pediatric patients 6 to 17 years 2
- Dihydroergotamine Mesylate Injection is indicated for acute treatment of migraine headaches with or without aura 3
From the Research
Treatment Options for Episodic Migraines
- The primary goal of treatment is to alleviate symptoms and improve quality of life 4, 5, 6, 7, 8
- Treatment options can be categorized into acute and preventive therapies
Acute Treatment
- Sumatriptan, a triptan, is an effective abortive medication for migraine attacks, relieving pain, nausea, photophobia, and phonophobia 4
- Oral sumatriptan has been shown to be effective in treating acute migraine attacks, with a significant reduction in pain scores and associated symptoms 4
- Intravenous valproate has been compared to subcutaneous sumatriptan in acute migraine attacks, with valproate showing faster and more effective relief without significant side effects 5
- Combination therapy, such as sumatriptan plus naproxen, has been shown to be effective in treating acute migraine attacks, with a greater effect than either monotherapy alone 7
Preventive Treatment
- Migraine prophylaxis should be implemented when more than three attacks occur per month, if attacks do not respond to acute treatment, or if the adverse effects of acute treatment are severe 6
- Substances with proven efficacy for migraine prophylaxis include beta-blockers (metoprolol and propranolol), calcium channel blockers (flunarizine), and anti-epileptic drugs (valproic acid) 6, 8
- Other options, such as botulinum toxin, are under investigation for migraine prophylaxis 8