What are the treatment options for acute migraine attacks?

Acute Migraine Treatment Options

For acute migraine attacks, first-line treatment should be NSAIDs for mild-to-moderate attacks, followed by triptans for moderate-to-severe attacks or when NSAIDs fail. 1

First-Line Treatment Options

Mild to Moderate Migraine Attacks

• NSAIDs (recommended doses):
  • Ibuprofen: 400-600 mg
  • Naproxen sodium: 500-550 mg
  • Diclofenac potassium
  • Aspirin
• Combination therapy: Acetaminophen plus aspirin plus caffeine (more effective than acetaminophen alone) 1

Moderate to Severe Migraine Attacks

• Triptans (recommended doses):
  • Sumatriptan: 50 mg orally for most patients, 6 mg subcutaneously for severe attacks or significant nausea/vomiting 1, 2
  • Rizatriptan: 10 mg orally for adolescents weighing ≥40kg, 50 mg for most adults (maximum 200 mg/24 hours) 1
  • Other triptans: Naratriptan (slower onset), zolmitriptan, almotriptan, frovatriptan, eletriptan 1

Treatment Algorithm Based on Severity and Symptoms

1. For mild-to-moderate attacks:

   • Start with NSAIDs or combination therapy (acetaminophen + aspirin + caffeine)
   • If inadequate response, escalate to triptans

2. For severe attacks or those with significant nausea/vomiting:

   • Start directly with triptans (sumatriptan 6 mg subcutaneously preferred for rapid onset) 1, 2
   • Add antiemetics even if vomiting is not present, as nausea itself is disabling 1

3. For attacks refractory to initial treatment:

   • Consider combination therapy of a triptan and an NSAID 1
   • Dihydroergotamine (DHE) intranasal as monotherapy 1
   • Antiemetics: Metoclopramide (particularly useful for patients with nausea/vomiting) or butorphanol nasal spray 1

4. For severe refractory attacks:

   • Rescue medications: Opioids (e.g., meperidine) or butalbital-containing compounds 1
   • CGRP receptor antagonists (rimegepant, ubrogepant) 1

Important Considerations and Precautions

Medication Limitations to Prevent Overuse Headache

• Sumatriptan: No more than 9 days per month 1
• OTC medications: No more than 14 days per month 1
• NSAIDs: No more than 15 days per month 1
• Ubrelvy: No more than 8 days per month 1

Contraindications

• Triptans are absolutely contraindicated in:
  • Uncontrolled hypertension
  • Cardiovascular disease
  • Basilar or hemiplegic migraine 1

Potential Adverse Effects

• Triptans: Chest discomfort, jaw or neck tightness, potential for coronary artery vasospasm 3
• Serotonin syndrome: Risk increases with concomitant use of triptans and SSRIs/SNRIs 3
• NSAIDs: Gastrointestinal effects, renal effects with prolonged use 4

Efficacy Evidence

Sumatriptan has demonstrated significant efficacy in randomized controlled trials:

• In clinical trials, 50-62% of patients achieved headache response within 2 hours with sumatriptan 50-100 mg compared to 17-27% with placebo 2
• Sumatriptan also showed significant reduction in associated symptoms like nausea, photophobia, and phonophobia 2

Non-Pharmacological Approaches

While medications are the mainstay of acute treatment, these complementary approaches can be helpful:

• Regular aerobic exercise and strength training
• Maintaining regular sleep schedule
• Adequate hydration
• Identification and avoidance of triggers
• Relaxation techniques or mindfulness 1

Remember that early intervention in a migraine attack improves treatment outcomes, and tracking headache patterns through a diary can help identify triggers and evaluate treatment response 1.