Acute Migraine Treatment Options
NSAIDs should be used as first-line therapy for acute migraine attacks, followed by triptans if NSAIDs fail. 1
First-Line Treatment Options
NSAIDs
For mild to moderate migraine attacks, NSAIDs are recommended as first-line therapy:
- Ibuprofen: 400-600 mg
- Naproxen sodium: 500-550 mg
- Aspirin: 1000 mg
- Diclofenac potassium
NSAIDs have demonstrated good evidence for efficacy in treating acute migraine attacks 1. They are generally less expensive than triptans and have fewer contraindications, making them appropriate initial choices for most patients.
Acetaminophen
- Acetaminophen alone is ineffective for migraine 2
- However, combination therapy with acetaminophen plus aspirin plus caffeine has good evidence for effectiveness 2
Second-Line Treatment Options
Triptans
For moderate to severe migraine attacks or when NSAIDs fail, triptans are recommended:
- Sumatriptan: 50 mg orally (standard dose), 6 mg subcutaneously for severe attacks or significant nausea/vomiting 1, 3
- Rizatriptan: 10 mg orally
- Zolmitriptan
- Naratriptan
- Eletriptan
- Frovatriptan
- Almotriptan
Clinical trials have demonstrated that triptans provide significant headache relief at 2 and 4 hours compared to placebo 3. Subcutaneous sumatriptan has a very rapid onset of action, while oral naratriptan has a slower onset 2.
Important safety considerations: Triptans are contraindicated in patients with:
Combination Therapy
The American College of Physicians recommends combination therapy of a triptan and an NSAID for patients with inadequate response to monotherapy 1. This approach may provide better relief than either medication alone.
Third-Line and Rescue Options
Antiemetics
- Metoclopramide: Particularly useful for patients with nausea and vomiting; can be used as monotherapy 2, 1
- Prochlorperazine
- Domperidone
Antiemetics should be considered even if vomiting is not present, as nausea itself can be disabling 1.
CGRP Receptor Antagonists
- Rimegepant
- Ubrogepant
These newer medications are suggested for short-term treatment of migraine 1.
Dihydroergotamine (DHE)
- Intranasal DHE has good evidence for efficacy as monotherapy 2
- Intravenous DHE has less established efficacy 2
Opioids
- Should be reserved for when other medications cannot be used or have failed 2, 1
- Butorphanol nasal spray has good evidence for efficacy 2
- Risk of medication overuse headache and dependence must be considered
Prevention of Medication Overuse Headache
To prevent medication overuse headache, limit acute therapy use to:
- Triptans: No more than 9 days per month
- NSAIDs: No more than 15 days per month
- OTC medications: No more than 14 days per month 1
Experts suggest limiting acute therapy to no more than twice per week 2.
Treatment Algorithm
For mild to moderate attacks:
- Start with NSAIDs (ibuprofen 400-600 mg or naproxen sodium 500-550 mg)
- Add an antiemetic if nausea is present
For severe attacks or if NSAIDs fail:
- Use a triptan (sumatriptan 50 mg orally or 6 mg subcutaneously for severe attacks)
- Consider combination of triptan and NSAID for enhanced efficacy
For refractory attacks:
- Consider DHE, antiemetics as monotherapy, or CGRP antagonists
- Reserve opioids for cases where other options are contraindicated or have failed
For patients with contraindications to vasoconstricting drugs:
- Use NSAIDs
- Consider antiemetics
- Consider combination analgesics without vasoconstrictive properties
Early treatment is crucial for optimal efficacy, and medication should be taken at the first sign of a definite migraine attack.