What are the treatment options for acute migraine management?

Acute Migraine Management

First-line treatment for acute migraine should be NSAIDs for mild to moderate attacks and triptans for moderate to severe attacks, with treatment selection based on attack severity and associated symptoms. 1, 2

First-Line Treatment Options

• NSAIDs are recommended as first-line therapy for mild to moderate migraine attacks, with options including aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 3
• Combination therapy of acetaminophen plus aspirin plus caffeine is effective for migraine treatment, but acetaminophen alone has limited efficacy 1, 3
• Triptans (serotonin1B/1D agonists) are recommended as first-line therapy for moderate to severe migraine attacks 2, 3
• Treatment should begin as early as possible during an attack for maximum efficacy, ideally while pain is still mild 1, 3

Second-Line Treatment Options

• If NSAIDs are ineffective, triptans should be used as second-line therapy 3
• Oral triptans with good evidence include naratriptan, rizatriptan, sumatriptan, and zolmitriptan 2, 4
• Among individual triptans, sumatriptan subcutaneous injection, rizatriptan ODT, zolmitriptan ODT, and eletriptan tablets are associated with the most favorable outcomes 5
• Triptans are most effective when taken early in an attack while headache is still mild, and if one triptan is ineffective, others may still provide relief 3

Non-Oral Routes for Patients with Nausea/Vomiting

• Select a non-oral route of administration for patients whose migraines present early with significant nausea or vomiting 3, 1
• Options include:
  • Subcutaneous sumatriptan (most rapid and effective triptan delivery) 2, 6
  • Intranasal zolmitriptan 7
  • Intranasal dihydroergotamine (DHE) 2, 8
• Antiemetics should be used not only for patients who are vomiting but also for those with significant nausea, as nausea itself is disabling 3

Third-Line Treatment Options

• For patients who fail all available triptans or have contraindications to their use, consider dihydroergotamine (DHE) 3, 2
• Antiemetics, particularly intravenous metoclopramide, may be appropriate as monotherapy for acute attacks, especially when nausea and vomiting are present 2
• For status migrainosus (severe, continuous migraine lasting up to one week), systemic steroid therapy is the treatment of choice 9

Important Considerations and Cautions

• Medication overuse headache can result from frequent use of acute medications (more than 2 days per week), leading to increasing headache frequency 1, 2
• Avoid opioids and butalbital-containing compounds for treating acute migraine headaches, as they can lead to dependency and medication overuse headache 1, 2
• Triptans are contraindicated in patients with ischemic or vasospastic coronary artery disease, Wolff-Parkinson-White Syndrome, or history of stroke or transient ischemic attack 7
• Combination therapy, such as triptan with NSAID, improves efficacy compared to either medication alone 10, 5

Treatment Algorithm for Acute Migraine

1. For mild to moderate attacks:

   • Start with NSAIDs (ibuprofen 400-800mg, naproxen sodium 500-550mg, aspirin 900-1000mg) 1, 3
   • If inadequate response, move to a triptan 3

2. For moderate to severe attacks:

   • Start with a triptan (sumatriptan 50-100mg, rizatriptan 10mg, zolmitriptan 2.5-5mg) 2, 5
   • Consider combination therapy with NSAID plus triptan for enhanced efficacy 10

3. For attacks with significant nausea/vomiting:

   • Use non-oral route: subcutaneous sumatriptan, intranasal zolmitriptan, or intranasal DHE 3, 2
   • Add an antiemetic (metoclopramide, prochlorperazine) 3, 9

4. For status migrainosus:

   • IV fluids for hydration 9
   • IV corticosteroids 9
   • Antiemetic therapy 9
   • If inadequate response, add parenteral NSAIDs such as ketorolac 9

Preventive Treatment Considerations

• Consider preventive therapy if patient experiences: 2+ attacks per month with disability lasting 3+ days per month, failure of acute treatments, use of acute medications more than twice weekly, or uncommon migraine conditions 3
• First-line preventive agents include propranolol (80-240 mg/d), timolol (20-30 mg/d), amitriptyline (30-150 mg/d), divalproex sodium (500-1500 mg/d), and sodium valproate (800-1500 mg/d) 3, 1