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

Migraine Treatment in Urgent Care

For most migraine sufferers presenting to urgent care, NSAIDs are the first-line therapy, followed by triptans if NSAIDs fail, with antiemetics added for nausea/vomiting. 1, 2

First-Line Treatment Algorithm

1. NSAIDs
   • Ibuprofen 400-600mg orally
   • Naproxen sodium 500-550mg orally
   • Aspirin (doses vary)
   • Combination of acetaminophen + aspirin + caffeine 2, 1

Note: There is no evidence supporting acetaminophen alone for migraine treatment 2

Second-Line Treatment (if NSAIDs fail)

1. Triptans
   • Sumatriptan:
     • 50mg orally for most patients (moderate to severe attacks)
     • 6mg subcutaneously for severe attacks or significant nausea/vomiting 1, 3
   • Rizatriptan 10mg orally
   • Naratriptan, zolmitriptan (oral) 2

The subcutaneous route provides the most rapid pain relief, with almost 6 in 10 patients (59%) achieving complete pain relief within 2 hours compared to only 15% with placebo 3

Important Considerations for Triptan Use

Contraindications

• Uncontrolled hypertension
• Cardiovascular disease or risk factors
• Basilar or hemiplegic migraine
• Concurrent use with MAO-A inhibitors 1

Administration Timing

• Triptans are most effective when taken early in an attack while headache is still mild 1
• Use should be limited to a maximum of 2 days per week to prevent medication overuse headache 1

Management of Nausea and Vomiting

• For patients with significant nausea/vomiting:
  • Use non-oral routes of administration (subcutaneous sumatriptan preferred)
  • Add an antiemetic medication 2
  • Antiemetics should be considered even if vomiting is not present, as nausea itself is disabling 2

Rescue Therapy (for refractory cases)

• Opioids (e.g., meperidine) or butalbital-containing compounds may be considered when:
  • First and second-line treatments have failed
  • Sedation side effects are not concerning
  • Risk for abuse has been addressed 2, 1

Pitfalls and Caveats

1. Medication Overuse Risk:

   • Limit triptan use to no more than 9 days per month
   • Limit OTC medications to no more than 14 days per month
   • Limit NSAIDs to no more than 15 days per month 1

2. Migraine Recurrence:

   • Approximately 40% of patients experience recurrence within 24 hours after initial relief with sumatriptan, likely due to its short half-life (2 hours) 4, 5
   • A second dose may be needed for recurrence 5

3. Cardiac Monitoring:

   • First-time users of subcutaneous sumatriptan with cardiovascular risk factors should receive cardiac monitoring 1

4. Patient Education:

   • Encourage tracking of headache characteristics and response to treatment
   • Help identify potential triggers (alcohol, caffeine, certain foods, stress, etc.) 1

Preventive Treatment Consideration

While urgent care focuses on acute treatment, consider preventive therapy evaluation for patients with:

• ≥2 attacks per month with significant disability
• Failure of or contraindication to acute treatments
• Use of abortive medications more than twice weekly
• Uncommon migraine conditions (hemiplegic, prolonged aura, migrainous infarction) 2, 1