What are the treatment options for acute migraine headaches?

From the Guidelines

Acute migraine treatment should begin with a combination of NSAIDs, such as ibuprofen 400-600mg or naproxen 500-550mg, and an antiemetic, like metoclopramide 10mg, taken at the first sign of headache. For mild to moderate migraine attacks, NSAIDs are the first-line therapy, with the most consistent evidence existing for aspirin, ibuprofen, naproxen sodium, tolfenamic acid, and the combination agent acetaminophen plus aspirin plus caffeine 1.

Treatment Options

• For moderate to severe migraines, triptans are the first-line specific treatment, with sumatriptan 50-100mg orally being commonly prescribed, as evidenced by studies showing good efficacy for oral naratriptan, rizatriptan, and zolmitriptan; oral and subcutaneous sumatriptan; and DHE nasal spray 1.
• Alternative triptans include rizatriptan 10mg, zolmitriptan 2.5-5mg, or eletriptan 40mg.
• For patients who experience nausea or vomiting, non-oral formulations such as sumatriptan nasal spray (20mg) or injection (6mg) may be more effective, as they can bypass the gastrointestinal tract and provide quicker relief 1.
• Combination medications like sumatriptan/naproxen can provide enhanced relief through complementary mechanisms.

Adjunctive Therapy

• Metoclopramide (Reglan) is sometimes recommended as a single agent in the treatment of migraine pain, but its main use is for treating accompanying nausea and improving gastric motility, which may be impaired during migraine attacks 1.
• Prochlorperazine (Compazine) can effectively relieve headache pain.
• Other adjunctive therapies for the abortive treatment of migraines are caffeine and sleep.

Important Considerations

• Patients should take medications early in the attack when pain is mild, limit use to 2-3 days per week to avoid medication overuse headache, and rest in a dark, quiet room while medications take effect.
• These treatments work by reducing inflammation, blocking pain pathways, and constricting dilated blood vessels in the brain that contribute to migraine pain.
• Patients with cardiovascular disease should avoid triptans and discuss alternative options with their healthcare provider 1.

From the FDA Drug Label

Sumatriptan tablets, USP are indicated for the acute treatment of migraine with or without aura in adults. Limitations of Use: Use only if a clear diagnosis of migraine headache has been established. The treatment options for acute migraine headaches include sumatriptan and rizatriptan, which are both indicated for the acute treatment of migraine with or without aura in adults 2, 2, 3.

• Sumatriptan is available in doses of 25,50, and 100 mg, and has been shown to be effective in the treatment of migraine headaches, with a significant percentage of patients achieving headache response 2 and 4 hours after treatment 2.
• Rizatriptan is also available for the acute treatment of migraine with or without aura in adults, but its use is contraindicated in patients with ischemic or vasospastic coronary artery disease, and caution should be exercised when administering it to patients with multiple cardiovascular risk factors 3.

From the Research

Treatment Options for Acute Migraine Headaches

The treatment options for acute migraine headaches are diverse and can be categorized into several groups.

• Over-the-counter analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen, and aspirin, are commonly used for mild to moderate migraine attacks 4, 5, 6.
• Triptans, such as sumatriptan and rizatriptan, are effective for moderate to severe migraine attacks or for attacks that do not respond to simple analgesics 4, 5.
• NSAID-triptan combinations, dihydroergotamine, non-opioid combination analgesics, and anti-emetics like metoclopramide and prochlorperazine are also available for acute migraine treatment 4, 7, 5.
• Alternative, non-drug treatment options include electrical nerve stimulation devices, magnetic stimulation devices, and behavioral medicine techniques like biofeedback training and mindfulness 7.
• Opioid-containing combination analgesics may be used in specific cases, but their use should be limited due to the risk of medication overuse and dependence 4, 5.

Considerations for Treatment Selection

When choosing an acute migraine medication, several clinical features should be considered, including:

• Usual headache intensity and rapidity of pain increase
• Presence of nausea, vomiting, and degree of disability
• Patient response to previously used medications
• History of headache recurrence with previous attacks
• Presence of contraindications to specific acute medications 4.

Special Considerations

In certain populations, such as pregnant or lactating women, and children and adolescents, the treatment options for acute migraine may be limited 5, 6.

• Acetaminophen and NSAIDs are commonly used in these populations, but their use should be carefully monitored and guided by a healthcare professional.
• Triptans and other prescription medications may be used in some cases, but their safety and efficacy in these populations are not well established 5, 8.