What is the acute management of a migraine attack?

Acute Management of Migraine Attack

NSAIDs are the first-line treatment for acute migraine attacks in adults, with recommended doses of ibuprofen 400-600 mg, naproxen sodium 500-550 mg, or aspirin 800-1000 mg. 1

Step-by-Step Approach to Acute Migraine Management

First-Line Treatment

• NSAIDs for mild to moderate attacks:
  • Ibuprofen 400-600 mg
  • Naproxen sodium 500-550 mg
  • Aspirin 800-1000 mg 1
• Antiemetics should be added when nausea and vomiting are prominent 1
• For patients with early nausea/vomiting, use non-oral routes of administration (subcutaneous, intranasal, rectal) 1

Second-Line Treatment

• Triptans for moderate to severe attacks or when NSAIDs fail:
  • Sumatriptan 50 mg orally for most patients
  • Sumatriptan 6 mg subcutaneously for severe attacks or significant nausea/vomiting 1, 2
  • Rizatriptan 10 mg orally (for adolescents ≥40kg) 1
• The FDA-approved sumatriptan indication specifically notes it should be used only after a clear diagnosis of migraine has been established 2

Third-Line Treatment

• Ditans (lasmiditan) or Gepants (ubrogepant, rimegepant) when triptans fail or are contraindicated 1
• These newer agents don't have the vascular contraindications of triptans 3

Refractory Attacks

• Consider combination therapy (triptan + NSAID)
• Antiemetics can be added as needed 1

Important Considerations

Medication Limitations to Prevent Overuse Headache

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

Contraindications for Triptans

Sumatriptan is contraindicated in patients with:

• History of coronary artery disease or vasospasm
• Wolff-Parkinson-White syndrome
• History of stroke, TIA, or hemiplegic/basilar migraine
• Peripheral vascular disease
• Ischemic bowel disease
• Uncontrolled hypertension
• Recent (within 24 hours) use of another triptan or ergotamine
• Recent (past 2 weeks) use of MAO-A inhibitors
• Severe hepatic impairment 2

Route of Administration

• Consider subcutaneous, intranasal, or rectal routes when nausea/vomiting are prominent 1
• Oral route is appropriate for most patients without significant nausea 2

Dosing Considerations

• Maximum sumatriptan dose in 24-hour period: 200 mg 2
• For patients with mild to moderate hepatic impairment, maximum single dose should not exceed 50 mg 2
• A second dose of sumatriptan should only be considered if some response to the first dose was observed, with doses separated by at least 2 hours 2

Common Pitfalls to Avoid

1. Delayed treatment: Early intervention during a migraine attack leads to better outcomes. Patients should be advised to take medication at the first sign of migraine.

2. Medication overuse: Strictly adhere to the recommended limitations on medication use to prevent medication overuse headache 1

3. Inappropriate use of opioids: Opioids and butalbital-containing medications are not recommended for migraine treatment unless other options have failed 3

4. Failure to address nausea: Antiemetics should be incorporated early when nausea is present 1

5. Misdiagnosis: The FDA label emphasizes that if a patient has no response to the first migraine attack treated with sumatriptan, reconsider the diagnosis before administering it for subsequent attacks 2