What are the recommended medications for migraine rescue?

Recommended Medications for Migraine Rescue

NSAIDs (ibuprofen, naproxen) or acetaminophen are recommended as first-line treatments for acute migraine attacks, with triptans as second-line options for patients with inadequate response to first-line treatments. 1

First-Line Treatment Options

• NSAIDs:

  • Ibuprofen (400-600mg)
  • Naproxen sodium (500-550mg)
  • Take at onset of headache with food to minimize gastrointestinal side effects
  • Evidence level: High

• Acetaminophen:

  • 1000mg dose
  • Option for patients who cannot take NSAIDs
  • Evidence level: Moderate

• Combination therapy:

  • Acetaminophen plus aspirin plus caffeine is effective for mild to moderate headaches
  • Avoid in patients with peptic ulcer disease or bleeding disorders

Second-Line Treatment Options: Triptans

Triptans are recommended when NSAIDs provide inadequate relief or for moderate to severe migraine attacks 2, 1:

• Sumatriptan:

  • Oral: 50-100mg (50mg offers best efficacy-to-tolerability ratio) 3, 4
  • Subcutaneous: 6mg (provides faster relief, especially with significant nausea/vomiting)
  • Intranasal: Option when oral route compromised by nausea

• Other oral triptans with good evidence of efficacy 2:

  • Rizatriptan: 10mg
  • Naratriptan
  • Zolmitriptan

Important triptan considerations:

• Take early in attack while pain is still mild (but not during aura phase)
• Non-oral formulations (subcutaneous, nasal) should be considered for patients with rapid peak headache intensity or vomiting 2, 1
• Contraindications: Uncontrolled hypertension, basilar or hemiplegic migraine, ischemic heart disease, previous myocardial infarction, Prinzmetal angina 5, 6
• Potential for serotonin syndrome when combined with SSRIs or SNRIs (monitor patients) 1, 5

Third-Line Treatment Options

For patients with inadequate response to triptans or when triptans are contraindicated 1:

• Gepants (CGRP antagonists):

  • Ubrogepant
  • Rimegepant
  • Evidence level: Moderate

• Ditans:

  • Lasmiditan
  • Evidence level: Moderate

• Intranasal DHE: Good evidence for efficacy and safety 2

• Butorphanol nasal spray: Good evidence for efficacy 2

• Opioids: Consider only if other medications cannot be used, risk of abuse has been addressed, and sedation is not a concern 2

Combination Therapy

• Consider combination therapy (triptan + NSAID) for patients with inadequate response to single agents 1
• No evidence suggests that combining triptans with gepants provides additional benefit over using either medication alone 1

Treatment of Nausea and Vomiting

• Nausea should be treated with an antiemetic drug 2
• Consider non-oral routes of administration when nausea or vomiting are significant components of migraine attacks 2

Medication Overuse Considerations

• Limit use of acute medications to prevent medication overuse headache:
  • Triptans: No more than 9 days per month
  • OTC medications: No more than 14 days per month
  • NSAIDs: No more than 15 days per month 1

Treatment Algorithm

1. For mild attacks: Start with NSAIDs or acetaminophen
2. For moderate to severe attacks or inadequate response to NSAIDs: Add or switch to a triptan
3. For patients with contraindications to triptans or inadequate response: Consider gepants, ditans, intranasal DHE, or butorphanol nasal spray
4. For patients with significant nausea/vomiting: Add an antiemetic and consider non-oral routes of administration

Remember that early treatment of migraine attacks leads to better outcomes, and selecting the appropriate rescue medication should be based on attack severity, associated symptoms, contraindications, and previous treatment response.