What is the initial management for acute migraine?

Management of Acute Migraine

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy for acute migraine attacks. 1, 2

First-Line Treatment Options

Mild to Moderate Migraine

• NSAIDs with strong evidence:

  • Ibuprofen: 400-800 mg every 6 hours (max initial dose: 800 mg, max daily: 2.4 g) 2, 1
  • Naproxen sodium: 275-550 mg every 2-6 hours (max initial dose: 825 mg, max daily: 1.5 g) 2, 1
  • Aspirin: 650-1000 mg every 4-6 hours (max initial dose: 1 g, max daily: 4 g) 2
  • Diclofenac potassium 3

• Combination therapy option:

  • Acetaminophen + aspirin + caffeine 2, 4

Note: Acetaminophen alone is NOT recommended for migraine 2

Moderate to Severe Migraine

• Migraine-specific medications (triptans):
  • Sumatriptan: 25 mg, 50 mg, or 100 mg (50 mg and 100 mg show better efficacy than 25 mg) 5
  • Rizatriptan, zolmitriptan, naratriptan 2, 1
  • Administer early in the attack for best results 6

Route of Administration Considerations

• For migraines with significant nausea/vomiting:
  • Use non-oral routes of administration 2
  • Options include:
    • Sumatriptan nasal spray or subcutaneous injection 5
    • Dihydroergotamine (DHE) nasal spray 2
    • Rectal NSAIDs 2

Adjunctive Therapy

• For nausea and vomiting:
  • Metoclopramide (Reglan): 10 mg IV or orally 20-30 minutes before or with primary medication 2
  • Prochlorperazine (Compazine): 25 mg orally or suppository (max 3 doses/24 hours) 2
  • These medications also improve gastric motility, which may be impaired during migraine attacks 2

Treatment Algorithm

1. Assess migraine severity:

   • Mild to moderate: Start with NSAIDs
   • Moderate to severe: Consider triptans or combination therapy

2. If first medication fails:

   • Try a different NSAID or triptan
   • Consider combination therapy (NSAID + triptan) which has better efficacy than either alone 4

3. For refractory migraines:

   • Dihydroergotamine (DHE) 2
   • Parenteral steroids and fluid replacement for status migrainosus 4

Important Cautions

• Avoid regular use of opioids and butalbital-containing analgesics due to risk of dependence and medication overuse headache 2, 1
• Monitor for medication overuse headache in patients using acute medications more than twice weekly 1
• NSAIDs are contraindicated in patients with:
  • Aspirin/NSAID-induced asthma
  • Bleeding disorders
  • G6PD deficiency (for aspirin) 2
• Triptans are contraindicated in patients with cardiovascular disease or risk factors

Special Populations

• Pregnancy: Acetaminophen is the safest option; acetaminophen with codeine is also an option 3
• Breastfeeding: Sumatriptan is compatible 3

Non-Pharmacological Approaches

• Maintain regular sleep and meal schedules
• Identify and avoid triggers using a headache diary
• Practice stress management techniques
• Maintain adequate hydration 1

Approximately 90% of migraine patients can be effectively managed in primary care with proper medication selection and dosing 1. Consider referral to a neurologist if treatments fail despite optimization or if diagnosis is uncertain.