From the Guidelines
The acute treatment of migraine headaches should start with a combination of a triptan and an NSAID or acetaminophen, as recommended by the American College of Physicians 1. This approach is based on the most recent and highest quality study available, which prioritizes the reduction of morbidity, mortality, and improvement of quality of life for patients with migraine headaches. The use of triptans, such as sumatriptan (50-100mg orally, 6mg subcutaneously, or 20mg intranasally), in combination with NSAIDs like ibuprofen (400-600mg) or naproxen sodium (500-550mg), or acetaminophen (1000mg), is supported by the evidence 1. For patients with severe nausea or vomiting, a nonoral triptan and an antiemetic, such as metoclopramide (10mg) or prochlorperazine (10mg), should be considered 1. Additionally, lifestyle modifications, including staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, engaging in regular physical activity, managing stress, and pursuing weight loss if applicable, are crucial in managing migraine headaches 1. It is essential to counsel patients on the potential complication of medication overuse headache and the importance of limiting acute medication use to 2-3 days per week 1. Newer treatments, such as gepants (rimegepant 75mg, ubrogepant 50-100mg) and ditans (lasmiditan 50-200mg), may be considered for patients who cannot take triptans or have inadequate response to other treatments 1. Some key points to consider when treating migraine headaches include:
- Starting treatment as soon as possible after the onset of symptoms
- Using combination therapy to improve efficacy
- Avoiding the use of opioids or butalbital for acute episodic migraine
- Discussing the potential adverse effects of pharmacologic treatments during pregnancy and lactation
- Exploring modifiable migraine triggers or contributing factors during a detailed history.
From the FDA Drug Label
Sumatriptan tablets, USP are indicated for the acute treatment of migraine with or without aura in adults. Single dose of 25 mg, 50 mg, or 100 mg tablet. A second dose should only be considered if some response to the first dose was observed. Separate doses by at least 2 hours. Maximum dose in a 24-hour period: 200 mg.
The acute treatment of migraine headaches is a single dose of 25 mg, 50 mg, or 100 mg of sumatriptan tablets, with a maximum dose in a 24-hour period of 200 mg 2, 2.
- The dose may be repeated after at least 2 hours if there is some response to the first dose.
- Key considerations for treatment include:
From the Research
Acute Treatment of Migraine Headaches
The primary goals of acute migraine therapy are to reduce attack duration and severity. Current evidence-based therapies for acute migraine attacks include:
- Acetaminophen 3
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, and aspirin 3, 4, 5, 6
- Triptans, which are migraine-specific medications 3, 4, 6
- NSAID-triptan combinations 3, 6
- Dihydroergotamine 3, 4, 6
- Non-opioid combination analgesics 3
- Anti-emetics, which can be used to alleviate nausea and vomiting 3, 5, 7, 6
Medications for Acute Migraine
Over-the-counter medications are an important component of migraine therapy and are considered a first-line therapy for most migraineurs. These medications have shown strong efficacy when used as first-line treatments for mild-to-moderate migraine attacks 3. Examples of effective over-the-counter medications include:
Administration and Dosage
The administration of acute migraine medications should follow the concept of "stratified care" 6. For mild to moderate migraine attacks, oral NSAIDs are the first choice, while for moderate to severe attacks, oral or nasal spray triptans and ergotamine/caffeine compounds are recommended 6. The dosage and frequency of medication use should be limited to prevent medication-overuse headache, with a maximum of ten days a month 6.