What is the treatment for acute migraine?

Treatment of Acute Migraine

The most effective approach to acute migraine treatment is a stepped care strategy, beginning with NSAIDs for mild to moderate attacks and triptans for moderate to severe attacks, with combination therapy for refractory cases. 1, 2, 3

First-Line Treatment Options

For Mild to Moderate Migraine Attacks:

• NSAIDs are the first-line treatment with strong evidence supporting acetylsalicylic acid (aspirin), ibuprofen, naproxen sodium, and diclofenac potassium 1, 3
• Ibuprofen provides pain relief in about half of sufferers, with NNTs for 2-hour headache relief of 3.2 (400mg) and 6.3 (200mg) compared to placebo 4
• Acetaminophen (paracetamol) is an alternative for patients who cannot tolerate NSAIDs but has less efficacy 1
• Combination medications containing acetaminophen, aspirin, and caffeine have demonstrated efficacy for mild to moderate attacks 3, 5

For Moderate to Severe Migraine Attacks:

• Triptans are the first-line treatment for moderate to severe attacks or when NSAIDs fail 1, 2, 3
• Sumatriptan shows significant efficacy with 50-62% of patients achieving headache response at 2 hours compared to 17-27% with placebo 6
• Triptans are most effective when taken early in an attack while pain is still mild 1, 3
• Alternative triptans include rizatriptan (faster onset, available as wafer), naratriptan (longer half-life), zolmitriptan, almotriptan, and frovatriptan 7

Second-Line and Combination Approaches

• For patients experiencing inadequate relief with a single agent, combining a triptan with an NSAID can provide superior efficacy 1, 2, 7
• If one triptan is ineffective, trying another triptan may provide relief 1, 7
• For patients with significant nausea/vomiting, non-oral routes should be considered:
  • Sumatriptan subcutaneous injection for rapid relief or when oral medications cannot be taken due to vomiting 1
  • Antiemetics (metoclopramide, prochlorperazine) can be used as adjuncts for nausea and provide synergistic analgesia 3

Third-Line Options for Refractory Migraine

• For patients who fail triptans and NSAIDs, newer options include:
  • Ditans (lasmiditan) - efficacy comparable to triptans but may cause driving impairment 1
  • Gepants (rimegepant, ubrogepant) - CGRP antagonists for patients who don't respond to or cannot tolerate triptans 2
  • Dihydroergotamine (DHE) intranasal or injectable for severe attacks 2, 3

Important Considerations and Cautions

• Start treatment as early as possible during the attack to improve efficacy 3
• Limit acute treatments to no more than twice weekly to prevent medication overuse headache 2, 3, 7
• Triptans are contraindicated in patients with:
  • Ischemic heart disease, coronary vasospastic conditions
  • Uncontrolled hypertension
  • Significant cardiovascular disease 8
• Do not use triptans and ergot derivatives together 7, 8
• Triptans may cause serotonin syndrome when combined with SSRIs or SNRIs 8
• For severe attacks requiring IV treatment, a combination of metoclopramide plus ketorolac is recommended 3

Special Populations

• For pregnant women, acetaminophen is the safest option 9
• For patients with significant nausea/vomiting, consider non-oral routes of administration or add antiemetics 3, 7
• For patients with contraindications to vasoconstricting medications, NSAIDs, combination analgesics without vasoconstrictors, and antiemetics are options 9

Treatment Algorithm

1. Assess attack severity:

   • Mild to moderate: Start with NSAIDs (ibuprofen, naproxen, aspirin, diclofenac) 1, 3
   • Moderate to severe: Start with a triptan 1, 2

2. If first treatment fails:

   • If NSAID fails: Try a triptan 1, 3
   • If triptan fails: Try a different triptan or combine triptan with NSAID 1, 7

3. For refractory attacks:

   • Consider dihydroergotamine, gepants, or ditans 1, 2
   • For severe attacks requiring emergency treatment: IV metoclopramide plus ketorolac 3

4. For patients with frequent recurrence:

   • Consider longer-acting triptans (naratriptan) 7
   • Evaluate for preventive therapy if acute treatments are needed more than twice weekly 2, 7