What are the treatment options for an acute migraine attack?

Treatment Options for Acute Migraine Attack

For acute migraine attacks, a stepped care approach should be used, starting with NSAIDs for mild to moderate attacks and progressing to triptans for moderate to severe attacks or when NSAIDs are ineffective. 1

First-Line Treatment Options

Mild to Moderate Attacks

• NSAIDs are recommended as first-line therapy due to their demonstrated efficacy and favorable tolerability profile 2, 1
• Specific NSAIDs with strong evidence include:
  • Aspirin (1000 mg) 3, 1
  • Ibuprofen 3, 1
  • Naproxen sodium 3, 1
  • Diclofenac potassium 1
• Combination therapy of acetaminophen plus aspirin plus caffeine is effective, though acetaminophen alone is not recommended 3, 2
• Treatment should begin as early as possible during an attack for maximum efficacy 1

Moderate to Severe Attacks

• Triptans (serotonin1B/1D agonists) are recommended for moderate to severe attacks or when NSAIDs fail 3, 1
• Effective oral triptans include:
  • Naratriptan 3
  • Rizatriptan 3
  • Sumatriptan 3
  • Zolmitriptan 3
• Sumatriptan tablets are indicated for acute treatment of migraine with or without aura in adults 4
• Clinical trials show that 50-62% of patients achieve headache response within 2 hours with sumatriptan tablets (25-100 mg) compared to 17-27% with placebo 4

Alternative Routes of Administration

• Select non-oral routes of administration for patients whose migraines present early with significant nausea or vomiting 3, 1
• Options include:
  • Subcutaneous sumatriptan (rapid onset of action) 3, 1
  • Intranasal sumatriptan 3, 1
  • Intranasal dihydroergotamine (DHE) 3, 1

Managing Associated Symptoms

• Treat nausea and vomiting with an antiemetic 3
• Antiemetics should not be restricted to patients who are vomiting or likely to vomit 3
• Intravenous metoclopramide may be appropriate as monotherapy for acute attacks, particularly in patients with nausea and vomiting 3, 1

Second-Line and Rescue Treatments

• If NSAIDs are ineffective, use migraine-specific agents (triptans, DHE) 3
• Oral opiate combinations and butorphanol may be considered when sedation side effects are not a concern and the risk for abuse has been addressed 3
• Opioids should be reserved for when other medications cannot be used 3, 1

Important Considerations and Cautions

• Limit acute therapy to no more than two times per week to guard against medication-overuse headache 3
• Medication-overuse headache can result from frequent use of acute medications (≥15 days/month with NSAIDs or ≥10 days/month with triptans) 2, 1
• Triptans are contraindicated in patients with:
  • History of coronary artery disease or coronary artery vasospasm 4
  • Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders 4
  • History of stroke, transient ischemic attack, or hemiplegic or basilar migraine 4
  • Peripheral vascular disease 4
  • Uncontrolled hypertension 4
  • Recent (within 24 hours) use of another triptan or ergotamine-containing medication 4

Preventive Treatment Considerations

• Evaluate migraine sufferers for use of preventive therapy if they have:
  • Two or more attacks per month that produce disability lasting 3 or more days per month
  • Contraindication to, or failure of, acute treatments
  • Use of abortive medication more than twice per week
  • Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura, or migrainous infarction) 3, 5
• First-line agents for prevention include propranolol, timolol, amitriptyline, divalproex sodium, and sodium valproate 3