What is the recommended management for an acute migraine attack?

Acute Migraine Management

For acute migraine attacks, first-line treatments include NSAIDs (ibuprofen or naproxen), acetaminophen, or a combination of NSAID + acetaminophen, with triptans recommended for more severe attacks. 1

First-Line Treatments by Severity

Mild to Moderate Attacks

• First choice: NSAIDs (ibuprofen, naproxen) or acetaminophen
• Dosing:
  • Ibuprofen: 400-800 mg
  • Naproxen: 500-550 mg
  • Acetaminophen: 1000 mg
• Timing: Take medication as early as possible during attack, preferably during mild pain phase for better outcomes 2

Moderate to Severe Attacks

• First choice: Triptan (such as sumatriptan) combined with an NSAID
• Dosing:
  • Sumatriptan: 50-100 mg orally (100 mg provides better pain relief than 50 mg) 1
  • Eletriptan: 20-40 mg (40 mg more effective than 20 mg) 3
• Second dose: May be administered if migraine has not resolved after 2 hours or returns after improvement, but wait at least 2 hours between doses 3
• Maximum daily dose: 80 mg for eletriptan 3

Second-Line Treatments

• CGRP antagonists (gepants): Rimegepant, ubrogepant, or zavegepant 1
• Antiemetics: Metoclopramide for associated nausea 1

Special Considerations

Medication Overuse Prevention

• Limit NSAIDs to ≤15 days/month
• Limit triptans to ≤10 days/month
• Exceeding these limits can lead to medication overuse headache 1, 3

Contraindications for Triptans

• Coronary artery disease or Prinzmetal's variant angina
• History of stroke or TIA
• Uncontrolled hypertension
• Wolff-Parkinson-White syndrome or other cardiac conduction disorders
• Within 24 hours of ergotamine use 3

Safety in Breastfeeding Women

• First choice: Acetaminophen
• Safe alternatives: Ibuprofen, sumatriptan
• For sumatriptan, consider avoiding breastfeeding for 12 hours after administration 1

Route of Administration Considerations

• Subcutaneous sumatriptan (6 mg) provides the most rapid pain relief (59% pain-free at 2 hours vs 15% with placebo) 4
• Oral sumatriptan (50 mg) provides complete pain relief in 28% of patients vs 11% with placebo 4
• Intranasal and rectal routes are alternatives when oral administration is not feasible 4

Monitoring and Follow-up

• Watch for potential adverse effects:
  • Triptan-related: Chest/throat/neck tightness, dizziness, paresthesia
  • Serious but rare: Serotonin syndrome (when combined with SSRIs/SNRIs/TCAs/MAOIs)
  • Cardiovascular: Blood pressure elevation, cardiac arrhythmias 3
• Maintain a headache diary to track frequency, severity, triggers, and medication response 1

Red Flags Requiring Urgent Evaluation

• Headache worsened with Valsalva maneuver
• Headache that awakens patient from sleep
• New-onset headache in older patients
• Progressively worsening headache pattern
• Neurological symptoms or abnormal neurologic examination
• Headache during sexual activity 1

Remember that early treatment during the mild pain phase significantly improves outcomes compared to waiting until pain becomes moderate or severe 2. The goal of acute treatment is to provide rapid, consistent, and complete pain relief with minimal adverse effects and prevent recurrence.