What are the initial treatment options for acute migraine management?

Acute Migraine Management

For initial treatment of acute migraine, NSAIDs (aspirin, ibuprofen, diclofenac potassium) are the first-line therapy for mild to moderate attacks, while triptans should be used as second-line therapy for moderate to severe attacks or when NSAIDs fail. 1, 2

Stepped Care Approach

First-Line Therapy (Mild to Moderate Attacks)

• NSAIDs with proven efficacy include aspirin (650-1000mg), ibuprofen, and diclofenac potassium 1
• Acetaminophen alone is not recommended for migraine treatment due to insufficient evidence 1, 2
• Combination analgesics containing acetaminophen plus aspirin plus caffeine are effective options 1, 3
• Begin treatment early in the headache phase for maximum effectiveness 1, 2

Second-Line Therapy (Moderate to Severe Attacks or NSAID Failure)

• Triptans (sumatriptan, rizatriptan, zolmitriptan, naratriptan) are the treatment of choice 1
• Triptans are most effective when taken early while headache is still mild 2, 4
• If one triptan is ineffective, others may still provide relief 1, 2
• Subcutaneous sumatriptan is particularly useful for patients with rapid-onset attacks or those with significant nausea/vomiting 1, 2

Third-Line Therapy (Refractory Attacks)

• Consider combining triptans with NSAIDs to prevent recurrence 1, 2
• CGRP antagonists (gepants) or ditans (lasmiditan) may be used when triptans fail or are contraindicated 1
• Dihydroergotamine (DHE) nasal spray is an alternative for selected patients 1, 5

Managing Associated Symptoms

• For patients with significant nausea or vomiting:
  • Use non-oral routes of administration 1
  • Add antiemetics such as metoclopramide or prochlorperazine to treat nausea and improve gastric motility 1, 2

Medications to Avoid

• Oral ergot alkaloids are poorly effective and potentially toxic 1, 6
• Opioids and barbiturates should be avoided due to questionable efficacy, risk of dependency, and potential for medication overuse headache 1, 7
• Acetaminophen alone lacks sufficient evidence for migraine treatment 1, 2

Preventing Medication Overuse Headache

• Limit acute medication use to prevent medication overuse headache: ≤15 days/month for NSAIDs, ≤10 days/month for triptans 2, 6
• Monitor frequency of medication use with headache diaries 2

Special Considerations

• For patients with contraindications to vasoconstricting drugs, NSAIDs, antiemetics, and non-triptan combination analgesics are options 5, 7
• For pregnant patients, acetaminophen is the safest option despite limited efficacy 5

Treatment Goals

• Treat attacks rapidly and consistently without recurrence 1
• Restore the patient's ability to function 1
• Minimize use of rescue medications 1
• Optimize self-care and cost-effectiveness 1
• Minimize adverse effects 1

By following this stepped care approach and selecting appropriate medications based on attack severity and individual response, most migraine attacks can be effectively managed with minimal disability and reduced risk of medication overuse.