What is the recommended treatment for migraine headaches in an urgent care setting?

Urgent Care Treatment for Migraine Headache

For acute migraine treatment in an urgent care setting, oral triptans (such as sumatriptan 50-100 mg) are recommended as first-line treatment for moderate to severe migraines, while NSAIDs (such as ibuprofen 400-800 mg or naproxen 500-550 mg) are recommended for mild to moderate migraines. 1

Initial Assessment and Stratified Treatment Approach

Severity-Based Treatment Algorithm:

• Mild to Moderate Migraine:

  • First-line: NSAIDs
    • Ibuprofen 400-800 mg
    • Naproxen sodium 500-550 mg
    • Diclofenac potassium
    • Aspirin 1000 mg
  • Alternative: Acetaminophen 1000 mg (if NSAIDs contraindicated) 1

• Moderate to Severe Migraine:

  • First-line: Oral triptans or triptan + NSAID/acetaminophen combination
    • Sumatriptan 50-100 mg (maximum 200 mg in 24 hours) 1, 2
    • Zolmitriptan 2.5-5 mg (maximum 10 mg in 24 hours) 1
    • Other triptans (rizatriptan, eletriptan) 1

Management of Associated Symptoms:

• For nausea/vomiting: Add antiemetic such as metoclopramide 10 mg 1
• For photophobia/phonophobia: Ensure quiet, dark environment while medications take effect 1

Dosing and Administration Details

Sumatriptan (Most Common Triptan):

• Recommended doses: 25 mg, 50 mg, or 100 mg orally 2
• Optimal dosing: 50 mg provides similar efficacy to 100 mg with potentially fewer side effects 2
• Second dose: May be administered if migraine persists after 2 hours 2
• Maximum daily dose: 200 mg in a 24-hour period 2
• Hepatic impairment: Maximum single dose should not exceed 50 mg in mild to moderate hepatic impairment 2

Clinical Response Expectations:

• In clinical trials, approximately 50-62% of patients achieved headache relief within 2 hours with sumatriptan 50-100 mg compared to 17-27% with placebo 2
• Approximately 70-79% achieved relief within 4 hours 2

Important Contraindications and Precautions

Triptan Contraindications:

• Coronary artery disease
• Uncontrolled hypertension
• History of stroke
• Cardiovascular disease 1

Medication Overuse Considerations:

• Avoid: Opioids and butalbital-containing medications due to risk of medication overuse headache and dependence 1, 3
• Limit: NSAID use to 2-3 days/week to prevent medication overuse headache 1

Second-Line Options

For Patients Who Cannot Take Triptans:

• CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant 1, 3
• Antiemetics with analgesic properties (metoclopramide, prochlorperazine) 1
• Acetaminophen 1000 mg (less effective than NSAIDs but better tolerated in some patients) 1, 4

For Refractory Migraines:

• Consider parenteral options if available in urgent care setting
• Consider combination therapy (triptan + NSAID) 1

Discharge Instructions and Follow-up

Patient Education:

• Maintain regular sleep schedule
• Manage stress
• Maintain regular physical activity
• Ensure adequate hydration and regular meals 1

When to Consider Preventive Therapy:

• Refer for preventive therapy evaluation if patient experiences:
  • 4 or more headaches per month
  • 8 or more headache days per month
  • Debilitating headaches
  • Medication-overuse headaches 1

When to Refer to Specialist:

• If two or more preventive medication trials fail
• If diagnosis uncertainty exists
• If complex comorbidities are present
• If advanced treatments like onabotulinumtoxinA are needed 1

Special Considerations

• Women with migraine with aura: Higher risk of ischemic stroke; avoid combined hormonal contraceptives with estrogens 1
• Medication overuse: Patients using acute medications more than 2-3 days/week are at risk for medication overuse headache 1
• Hepatic impairment: Reduce triptan dosage (maximum 50 mg for sumatriptan) 2

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