What are the recommended treatments for managing a migraine attack?

From the Guidelines

The most effective approach to managing a migraine attack involves a combination of medication and non-medication strategies, with a focus on early intervention and individualized treatment plans. For mild to moderate migraines, over-the-counter pain relievers like ibuprofen (400-600mg) or naproxen sodium (500-550mg) can be effective when taken early in the attack 1. For more severe migraines, prescription medications called triptans such as sumatriptan (50-100mg orally, 6mg subcutaneously, or 20mg nasal spray) or rizatriptan (10mg) are often recommended 1.

Some key points to consider in managing migraine attacks include:

• Selecting a nonoral route of administration for patients whose migraines present early with nausea or vomiting as a significant component of the symptom complex, and treating nausea and vomiting with an antiemetic 1
• Evaluating migraine sufferers for use of preventive therapy, particularly those with two or more attacks per month that produce disability lasting 3 or more days per month 1
• Recommending first-line agents for the prevention of migraine headache, such as propranolol (80 to 240 mg/d), timolol (20 to 30 mg/d), amitriptyline (30 to 150 mg/d), divalproex sodium (500 to 1500 mg/d), and sodium valproate (800 to 1500 mg/d) 1
• Educating migraine sufferers about the control of acute attacks and preventive therapy, and engaging them in the formulation of a management plan 1

Non-medication approaches can also be beneficial, such as:

• Resting in a dark, quiet room to reduce sensory stimulation that worsens symptoms
• Applying cold or warm compresses to the head or neck for relief
• Staying hydrated and practicing relaxation techniques such as deep breathing or meditation to help manage symptoms 1

It's essential to take acute medications as early as possible in the attack for maximum effectiveness and to avoid overuse (limiting use to 2-3 days per week) to prevent medication overuse headaches 1. By considering these factors and individualizing treatment plans, healthcare providers can help patients effectively manage their migraine attacks and improve their quality of life.

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 trials, doses of 25,50, and 100 mg were compared with placebo in the treatment of migraine attacks. 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

The recommended treatment for managing a migraine attack is sumatriptan tablets at doses of 25 mg, 50 mg, or 100 mg.

• The treatment is effective in achieving headache response (reduction in headache severity from moderate or severe pain to mild or no pain) within 2 and 4 hours after dosing.
• Associated symptoms such as nausea, photophobia, and phonophobia are also improved.
• A second dose of sumatriptan tablets or other medication is allowed 4 to 24 hours after the initial treatment for recurrent headache 2.

From the Research

Migraine Attack Management

Migraine attack management involves various treatment options to reduce the severity and duration of the attack. The following are some of the recommended treatments:

• Mild Migraine Attacks:
  • Antiemetics followed by analgesics such as aspirin, paracetamol, or nonsteroidal anti-inflammatory drugs (NSAIDs) 3
  • Acetaminophen, ibuprofen, naproxen, and aspirin are effective over-the-counter medications for mild-to-moderate migraine attacks 4
• Moderate to Severe Attacks:
  • Antiemetics combined with ergotamine or dihydroergotamine 3
  • Triptans, such as sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, and naratriptan, are effective for acute migraine treatment 5
  • Combination of a triptan and a NSAID can yield better efficacy compared to either therapy alone 6
• Acute Migraine Therapy:
  • The primary goals of acute migraine therapy are to reduce attack duration and severity 4
  • Current evidence-based therapies for acute migraine attacks include acetaminophen, NSAIDs, triptans, NSAID-triptan combinations, dihydroergotamine, non-opioid combination analgesics, and anti-emetics 4
• Treatment Strategies:
  • The acetaminophen-NSAID strategy is suitable for patients with attacks of mild to moderate severity 5
  • The triptan strategy is suitable for patients with severe attacks and for those with attacks of moderate severity who do not respond well to NSAIDs 5
  • Refractory migraine strategies may be useful for patients who do not respond well to NSAIDs or triptans alone 5
• 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
  • Opiates are not recommended for acute migraine treatment due to serious adverse events 6