What are the recommended rescue medications for migraine?

Recommended Rescue Medications for Migraine

Opioids (such as meperidine) or butalbital-containing compounds are the recommended rescue medications for severe migraine attacks that do not respond to first-line or second-line treatments. 1

Understanding Rescue Therapy for Migraine

Rescue medications are specifically intended for use when a patient's regular acute migraine treatments have failed. These medications:

• Allow patients to achieve relief without requiring emergency department visits
• May not completely eliminate pain but provide sufficient relief
• Should be used within a cooperative arrangement between provider and patient
• Are meant for occasional use when other treatments fail

First and Second-Line Treatments (Before Rescue)

Before considering rescue medications, patients should try the established treatment algorithm:

1. First-line treatments:

   • NSAIDs (ibuprofen 400-600mg, naproxen sodium 500-550mg)
   • Acetaminophen-aspirin-caffeine combination
   • Note: Acetaminophen alone is ineffective 1, 2

2. Second-line treatments (when NSAIDs fail):

   • Triptans (sumatriptan, rizatriptan, naratriptan, zolmitriptan)
   • Dihydroergotamine (DHE) intranasal spray
   • Note: Triptans are contraindicated in patients with uncontrolled hypertension, basilar/hemiplegic migraine, or cardiovascular disease risk 1, 2

Recommended Rescue Medications

When first and second-line treatments fail, the following rescue options are recommended:

1. Opioids:

   • Can be used when other medications cannot be used 1
   • Effective options include meperidine, tramadol, and nalbuphine 3
   • Should only be used after addressing risk of abuse
   • Should be avoided when sedation is a concern

2. Butalbital-containing compounds:

   • Can be used as rescue medication when other treatments fail 1
   • Often combined with caffeine and/or acetaminophen

3. Antiemetics:

   • Metoclopramide (IV) may be appropriate as monotherapy for acute attacks 1
   • Particularly useful in patients with nausea and vomiting

Special Considerations for Rescue Therapy

• Non-oral routes: Consider when significant nausea/vomiting is present 1

  • Sumatriptan subcutaneous injection (6mg)
  • Intranasal DHE
  • Add antiemetic medication to treat nausea

• Medication overuse risk: Limit acute therapy to no more than twice weekly to prevent medication-overuse headache 1, 2

• Headache recurrence: Corticosteroids can reduce headache recurrence after initial treatment 3

Cautions and Contraindications

• Medication overuse headache: Can result from frequent use of acute medications, including opioids, triptans, and analgesics containing butalbital, caffeine, or isometheptene 1

• Opioid side effects: Include dizziness, sedation, and nausea 3

• Triptan contraindications: Uncontrolled hypertension, basilar or hemiplegic migraine, cardiovascular disease risk 1, 4

Algorithm for Rescue Medication Selection

1. If patient has no contraindications to opioids and sedation is not a concern:

   • Prescribe opioid (meperidine, tramadol, or nalbuphine)

2. If patient has contraindications to opioids or concerns about abuse:

   • Consider butalbital-containing compound

3. If patient has significant nausea/vomiting:

   • Add antiemetic (metoclopramide)
   • Consider non-oral route of administration

4. If concerned about headache recurrence:

   • Consider adding corticosteroid

Remember that rescue medications should be limited to occasional use when other treatments fail, with a clear understanding between provider and patient about appropriate situations for use 1.