What is the best treatment for acute migraine headache?

From the Guidelines

The most effective treatment for acute migraine headache is early intervention with medications like NSAIDs or triptans, with aspirin-acetaminophen-caffeine being a strong recommendation for acute migraine treatment. For mild to moderate migraines, over-the-counter options such as ibuprofen (400-600mg), naproxen sodium (500-550mg), or aspirin (1000mg) can be effective when taken at the first sign of headache 1. For moderate to severe migraines, prescription triptans like sumatriptan (50-100mg orally, 6mg subcutaneously, or 20mg nasal spray) are often more effective. These work by constricting blood vessels and blocking pain pathways in the brain.

• Key considerations for treatment include:
  • Time to pain freedom and freedom from most bothersome symptom
  • Restoration of function
  • Minimizing the use of back-up and rescue medications
  • Optimizing self-care for overall management
  • Being cost-effective in overall management
  • Causing minimal or no adverse effects
• Non-pharmacologic therapies such as behavioral medicine interventions, rehabilitation interventions, and neuromodulation may also be considered, with rehabilitation delivered through physical therapy receiving a weak for recommendation for the management of migraine and TTH 1.
• It is essential to work with a healthcare provider to craft a treatment plan that accounts for headache type or types, comorbid conditions, and values and preferences.
• Frequent use of acute medications (more than 10-15 days per month) should be avoided as it can lead to medication overuse headaches.
• The use of newer CGRP inhibitors (gepants) and other pharmacotherapies should be considered based on individual patient needs and preferences, with a strong recommendation for aspirin-acetaminophen-caffeine for acute migraine treatment 1.

From the FDA Drug Label

The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. In all 3 trials, the percentage of patients achieving headache response 2 and 4 hours after treatment was significantly greater among patients receiving sumatriptan tablets at all doses compared with those who received placebo The results from the 3 controlled clinical trials are summarized in Table 2. For patients with migraine-associated nausea, photophobia, and/or phonophobia at baseline, there was a lower incidence of these symptoms at 2 hours (Trial 1) and at 4 hours (Trials 1,2, and 3) following administration of sumatriptan tablets compared with placebo

The best treatment for acute migraine headache is sumatriptan tablets at doses of 25 mg, 50 mg, or 100 mg, as they have been shown to be effective in reducing headache severity and associated symptoms compared to placebo 2.

• Key benefits of sumatriptan tablets include:
  • Significant reduction in headache severity at 2 and 4 hours after treatment
  • Lower incidence of migraine-associated nausea, photophobia, and phonophobia
  • Effective at all doses (25 mg, 50 mg, and 100 mg) compared to placebo Note that the 50 mg and 100 mg doses may have a greater percentage of patients with headache response at 2 and 4 hours compared to the 25 mg dose.

From the Research

Treatment Options for Acute Migraine Headache

The best treatment for acute migraine headache depends on various factors, including the severity of the headache, presence of nausea and vomiting, and patient's medical history. According to the studies 3, 4, 5, 6, 7, the following treatment options are available:

• Over-the-counter analgesics such as acetaminophen, ibuprofen, and naproxen
• Nonsteroidal anti-inflammatory medications (NSAIDs) such as diclofenac potassium and acetylsalicylic acid
• Triptans such as sumatriptan, rizatriptan, and eletriptan
• Ergots such as dihydroergotamine
• Anti-emetics such as metoclopramide and prochlorperazine
• Combination analgesics containing acetaminophen, ASA, and caffeine

Treatment Strategies

The studies 3, 5 suggest that treatment strategies can be organized into four categories:

• Strategy one: acetaminophen and/or NSAIDs for mild to moderate attacks
• Triptan strategy for patients with severe attacks and for attacks not responding to strategy one
• Refractory attack strategy for patients who do not respond well to NSAIDs or triptans alone
• Strategy for patients with contraindications to vasoconstricting drugs, including use of NSAIDs, combination analgesics, and dopamine antagonists

Special Considerations

According to the studies 3, 5, 6, special considerations should be taken into account when treating acute migraine headache in certain populations, such as:

• Pregnancy: acetaminophen is the safest option, and sumatriptan may be an option for selected patients
• Lactation: acetaminophen and sumatriptan are compatible with breast-feeding
• Children and adolescents: acetaminophen, ibuprofen, intranasal sumatriptan, and intranasal zolmitriptan may be effective, although data is limited

Emerging Treatments

The study 7 mentions that new treatments are emerging, including:

• Gepants (small-molecule calcitonin gene-related peptide [CGRP] receptor antagonists)
• Ditans (stimulators of 5-HT1F receptors)
• Electrical nerve stimulation devices and magnetic stimulation devices
• Behavioral medicine techniques such as biofeedback training and mindfulness