What are the treatment options for acute migraines?

Acute Treatment of Migraines

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy for acute migraine attacks, followed by triptans for moderate to severe attacks or when NSAIDs fail. 1

Stepped Care Approach for Acute Migraine Treatment

First-Line Treatment (Mild to Moderate Attacks)

• NSAIDs with proven efficacy:

  • Aspirin (650-1000 mg)
  • Ibuprofen (400-800 mg)
  • Naproxen sodium (275-550 mg)
  • Diclofenac potassium 1

• Other first-line options:

  • Combination analgesics containing caffeine (e.g., aspirin plus acetaminophen plus caffeine)
  • Isometheptene combinations 1

Note: Acetaminophen alone is not recommended for migraine as evidence does not support its efficacy 1. The NNT of 12 for pain-free response at two hours is inferior to other commonly used analgesics 2.

Second-Line Treatment (Moderate to Severe Attacks or First-Line Failure)

• Triptans with proven efficacy:
  • Sumatriptan (oral, subcutaneous, nasal)
  • Rizatriptan
  • Eletriptan
  • Zolmitriptan
  • Almotriptan
  • Frovatriptan
  • Naratriptan 1, 3, 4

Clinical pearl: Triptans are most effective when taken early in an attack when headache is still mild 1. Sumatriptan has shown efficacy with 61-62% of patients achieving headache response at 2 hours with the 50-100 mg dose compared to 17-27% with placebo 3.

Third-Line Treatment (Triptan Failure or Contraindications)

• Options include:
  • Dihydroergotamine (DHE) nasal spray
  • Combination therapy (triptan + NSAID)
  • Newer agents (if available):
    • Ditans (lasmiditan)
    • CGRP antagonists-gepants (rimegepant, ubrogepant, zavegepant) 1

Special Considerations for Nausea/Vomiting

• For migraine with significant nausea/vomiting:
  • Use non-oral routes of administration
  • Add antiemetics such as:
    • Metoclopramide (10 mg)
    • Prochlorperazine
    • Domperidone 1

Algorithm for Acute Migraine Treatment

1. Assess migraine severity:

   • Mild to moderate: Start with NSAIDs
   • Moderate to severe: Consider starting with triptans

2. If using NSAIDs:

   • Ensure adequate dosing
   • If inadequate response after 2 hours, add a triptan

3. If using triptans:

   • If one triptan is ineffective, try another (patients may respond differently)
   • For rapid onset attacks or those with vomiting, consider non-oral routes (subcutaneous sumatriptan)

4. For treatment failures:

   • Try combination of triptan + NSAID simultaneously
   • Consider DHE or antiemetics as rescue medications

5. For patients with contraindications to vasoconstricting drugs:

   • Use NSAIDs
   • Consider antiemetics
   • Avoid triptans and ergots

Important Caveats and Pitfalls

• Medication overuse headache: Limit use of acute medications to ≤2 days/week to prevent medication overuse headache 1

• Opioids: Limit and carefully monitor the use of opioids and butalbital-containing analgesics; these should not be used routinely 1

• Triptan contraindications: Avoid in patients with cardiovascular disease, uncontrolled hypertension, or hemiplegic migraine

• Timing of medication: Take medication early in an attack for best results, but triptans should not be taken during the aura phase 1

• Recurrence: Some patients experience headache recurrence within 48 hours; they may repeat triptan treatment or combine with fast-acting NSAIDs, but should be warned this increases risk of medication overuse headache 1

By following this evidence-based approach to acute migraine treatment, clinicians can effectively manage migraine attacks while minimizing adverse effects and reducing the risk of medication overuse headache.