What is the recommended initial treatment for emergency migraine management?

Emergency Treatment of Migraine

For emergency migraine management, NSAIDs (such as ibuprofen, naproxen sodium, or aspirin) are recommended as first-line treatment, with triptans reserved for moderate to severe attacks or when NSAIDs fail to provide relief. 1

First-Line Treatment Algorithm

1. NSAIDs (for mild to moderate migraine attacks):

   • Ibuprofen: 400-800 mg every 6 hours (maximum 2.4g daily)
   • Naproxen sodium: 275-550 mg every 2-6 hours (maximum 1.5g daily)
   • Aspirin: 650-1000 mg every 4-6 hours (maximum 4g daily)
   • Combination of acetaminophen-aspirin-caffeine 2

   Note: Acetaminophen alone is ineffective for migraine treatment and should not be used as monotherapy 2, 1

2. For moderate to severe migraine or when NSAIDs fail:

   • Triptans (migraine-specific medications):
     • Sumatriptan: 50-100 mg orally (100 mg may not provide greater effect than 50 mg but may have more side effects) 3
     • Rizatriptan: 5-10 mg orally
     • Zolmitriptan: 2.5-5 mg orally
     • Naratriptan: 1-2.5 mg orally 1

Special Considerations

For migraine with significant nausea/vomiting:

• Use non-oral routes of administration 2:
  • Sumatriptan subcutaneous injection (6 mg)
  • Intranasal triptans
  • Add an antiemetic such as metoclopramide (Reglan) or prochlorperazine (Compazine) 2

For refractory cases:

• Ketorolac (Toradol) - parenteral NSAID with rapid onset 2
• Dihydroergotamine (DHE) - intranasally administered 2
• Opioids only if other medications cannot be used and abuse risk has been addressed 2

Important Cautions

• Triptan contraindications: Uncontrolled hypertension, basilar or hemiplegic migraine, coronary artery disease, or within 24 hours of ergotamine use 2

• Medication overuse risk: Limit acute therapy to no more than twice per week to prevent medication-overuse headache 1

• Opioid use: Should be avoided for chronic daily headaches due to dependency risk, rebound headaches, and eventual loss of efficacy 2

Treatment Approach

The "stratified-care" approach (assigning treatment based on migraine severity) is superior to the "step-care" approach (starting with safest/cheapest and progressing to more expensive options only when initial treatment fails) 2.

Efficacy Considerations

• Triptans are highly effective, with studies showing headache relief in 50-67% of patients within 2 hours after oral administration and 70-80% within 1 hour after subcutaneous administration 4, 5

• Approximately 40% of patients may experience headache recurrence within 24 hours after initial relief with triptans, but most respond well to a second dose 5

• When comparing oral medications, sumatriptan 100mg has shown greater efficacy than ergotamine 2mg plus caffeine 200mg combination and aspirin 900mg plus metoclopramide 10mg 5

By following this evidence-based approach to emergency migraine management, clinicians can provide effective relief while minimizing risks of medication overuse and adverse effects.