What is the best medication for treating migraines in an inpatient setting?

Best Medications for Migraine Treatment in the Inpatient Setting

For inpatient treatment of acute migraine, the combination of a triptan with an NSAID is recommended as first-line therapy, with metoclopramide plus diphenhydramine as an effective alternative for patients with severe nausea or vomiting. 1, 2

First-Line Treatment Options

• The combination of a triptan (such as sumatriptan or rizatriptan) with an NSAID (such as naproxen) provides superior pain relief compared to monotherapy, with higher rates of pain freedom at 2 hours (moderate-certainty evidence) 1
• This combination therapy results in sustained pain relief up to 48 hours (180 more events per 1000 treated people; high-certainty evidence) and reduces the need for rescue medication (160 fewer events per 1000 treated people) 1
• For patients who cannot tolerate NSAIDs, adding a triptan to acetaminophen is an effective alternative (conditional recommendation; low-certainty evidence) 1

Treatment for Patients with Severe Nausea/Vomiting

• For patients with severe nausea or vomiting, consider using a nonoral triptan formulation (nasal spray or injectable) along with an antiemetic 1
• Metoclopramide (10 mg IV) with diphenhydramine (25 mg IV) is an effective treatment for acute migraine in the inpatient setting 3, 4
• Prochlorperazine (10 mg IV) with diphenhydramine (25 mg IV) has shown similar efficacy to metoclopramide for acute migraine relief 4

Second-Line Treatment Options

• For patients who don't respond to or cannot tolerate first-line treatments, CGRP antagonists-gepants may be considered, though they may have lower likelihood of pain freedom compared to triptan-NSAID combinations 1, 2
• Dihydroergotamine (DHE) may be used for severe migraine not responding to other treatments, but it may cause more nausea and vomiting than triptan therapy 1, 5
• Intravenous valproate (500 mg) has shown similar effectiveness to intramuscular dihydroergotamine/metoclopramide for acute migraine treatment with potentially fewer side effects 5

Important Considerations and Cautions

• Opioids and butalbital-containing medications should be avoided for migraine treatment due to risk of medication overuse headache and dependency 1, 6, 7
• Medication overuse headache can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
• Treatment should begin as soon as possible after headache onset to maximize efficacy 2
• Consider adding a steroid (such as dexamethasone) to reduce the risk of headache recurrence after discharge from the inpatient setting 7

Treatment Algorithm

1. Initial Assessment:

   • Assess pain severity, associated symptoms (nausea, vomiting, photophobia, phonophobia)
   • Evaluate for contraindications to specific medications

2. First-Line Treatment:

   • For moderate to severe pain without significant nausea/vomiting:
     • Triptan (sumatriptan or rizatriptan) plus NSAID (naproxen) 1
   • For patients with NSAID contraindications:
     • Triptan plus acetaminophen 1
   • For patients with severe nausea/vomiting:
     • Metoclopramide 10 mg IV plus diphenhydramine 25 mg IV 3, 4
     • OR Prochlorperazine 10 mg IV plus diphenhydramine 25 mg IV 4

3. If Inadequate Response After 1-2 Hours:

   • Consider adding dihydroergotamine if no cardiovascular contraindications 5
   • OR intravenous valproate 500 mg 5
   • OR CGRP antagonist-gepant 1, 2

4. Before Discharge:

   • Consider adding a steroid to reduce risk of headache recurrence 7
   • Provide education on medication overuse headache prevention 1
   • Discuss preventive strategies if patient experiences frequent migraines 2

By following this evidence-based approach, clinicians can effectively manage acute migraine in the inpatient setting while minimizing adverse effects and reducing the risk of headache recurrence.