What are the treatment options for a migraine attack?

Migraine Attack Treatment

For acute migraine attacks, first-line treatment should be NSAIDs (such as ibuprofen 400-600mg) for mild to moderate attacks, and triptans plus NSAIDs for moderate to severe attacks, with combination therapy providing superior relief. 1

First-Line Treatment Options

Mild to Moderate Migraine Attacks

• NSAIDs:
  • Ibuprofen: 400-600mg
  • Naproxen sodium: 500-550mg
  • Aspirin: 800-1000mg
  • Acetaminophen: 1000mg

Moderate to Severe Migraine Attacks

• Triptans (with or without NSAIDs):
  • Sumatriptan: 50mg orally (standard) or 6mg subcutaneously for severe attacks with significant nausea/vomiting
  • Rizatriptan: 10mg orally for patients weighing ≥40kg

Clinical trials demonstrate that sumatriptan provides significantly better pain-free response and headache relief compared to placebo, with NNTs of 4.7 for pain-free at two hours and 3.5 for headache relief at two hours with the 100mg dose 2. The FDA-approved studies show that 50-62% of patients achieve headache response within 2 hours with sumatriptan tablets versus 17-27% with placebo 3.

Second-Line Treatment Options

When first-line treatments fail or are contraindicated:

• Antiemetics: For significant nausea/vomiting

• CGRP Antagonists (Gepants):

  • Rimegepant
  • Ubrogepant
  • Zavegepant

• Ditans:

  • Lasmiditan (especially when triptans are contraindicated due to cardiovascular concerns)

Treatment Algorithm

1. Assess migraine severity:

   • Mild to moderate: Start with NSAIDs
   • Moderate to severe: Use triptans + NSAIDs

2. If inadequate response to NSAIDs:

   • Add or switch to a triptan
   • Initiate treatment as early as possible in the attack

3. If inadequate response to triptans or contraindications exist:

   • Try CGRP antagonists (gepants) or ditans

4. For significant nausea/vomiting:

   • Add an antiemetic
   • Consider non-oral routes (subcutaneous sumatriptan 6mg)

Important Considerations

• Timing: Initiate treatment as soon as possible after headache onset for best results 1

• Medication overuse: Limit use of triptans to no more than 9 days per month and NSAIDs to no more than 15 days per month to prevent medication overuse headache 1

• Contraindications: Triptans are contraindicated in patients with:

  • Coronary artery disease
  • Prinzmetal's variant angina
  • History of stroke or TIA
  • Uncontrolled hypertension
  • Wolff-Parkinson-White syndrome 3

• Monitoring: Track headache frequency, severity, duration, disability, response to treatment, and adverse effects using a headache diary 1

Adverse Effects

• Sumatriptan: Sensations of tightness, pain, pressure in chest/throat/neck/jaw (usually non-cardiac), elevated blood pressure, and serotonin syndrome (especially when combined with SSRIs/SNRIs) 3
• NSAIDs: Gastrointestinal issues, renal effects with prolonged use

Medications to Avoid

• Opioids and butalbital-containing medications: Not recommended for migraine treatment due to risk of medication overuse headache and worsening sleep 1, 4

Non-Pharmacological Approaches

• Regular aerobic exercise or strength training (2-3 times/week for 30-60 minutes)
• Trigger identification and avoidance
• Maintaining regular sleep schedule
• Adequate hydration
• Relaxation techniques or mindfulness 1

By following this treatment approach and considering individual contraindications, most migraine attacks can be effectively managed with reduced disability and improved quality of life.