What is the recommended dosage for acute migraine treatment?

Recommended Dosages for Acute Migraine Treatment

For most migraine sufferers, NSAIDs are first-line therapy, followed by triptans for those who don't respond to NSAIDs, with specific recommended dosages for each medication class. 1

First-Line Treatment: NSAIDs

• NSAIDs with the most consistent evidence include aspirin, ibuprofen, naproxen sodium, and the combination of acetaminophen plus aspirin plus caffeine 1
• Acetaminophen alone is not recommended due to lack of evidence 1

Second-Line Treatment: Triptans

When NSAIDs fail to provide relief, use triptans with the following dosages:

• Sumatriptan:
  • Oral: 25-100 mg (100 mg most effective but with more side effects) 2
  • Subcutaneous: 6 mg (provides relief within 10 minutes) 3
• Rizatriptan:
  • Can be taken every two hours as needed, not exceeding maximum daily dose 4
  • Orally disintegrating tablets beneficial when nausea/vomiting are present 4
• Zolmitriptan:
  • Starting dose: 1.25 mg or 2.5 mg 5
  • Maximum single dose: 5 mg 5
  • May repeat dose after 2 hours if needed; not to exceed 10 mg in any 24-hour period 5
  • For moderate or severe hepatic impairment: 1.25 mg recommended 5

Third-Line Treatment: Newer Agents

• Ubrogepant: Consider for patients who don't tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen 6

Route of Administration Considerations

• Select non-oral routes of administration (subcutaneous, nasal) for patients whose migraines present early with significant nausea or vomiting 1
• Consider adding an antiemetic for patients with significant nausea or vomiting during migraine attacks 6

Treatment Timing and Approach

• Begin treatment as soon as possible after migraine onset for optimal efficacy 6
• Try a triptan for 2-3 migraine episodes before determining effectiveness 4
• If one triptan is ineffective, try a different triptan 4

Important Safety Considerations

• Monitor for medication overuse headache with frequent use of acute treatments 6, 4
• Triptans are contraindicated in patients with:
  • History of coronary artery disease or coronary vasospasm 5
  • Wolff-Parkinson-White syndrome or other cardiac conduction disorders 5
  • History of stroke, transient ischemic attack, or hemiplegic/basilar migraine 5
  • Peripheral vascular disease or ischemic bowel disease 5
  • Uncontrolled hypertension 5
  • Recent (within 24 hours) use of another triptan or ergotamine-containing medication 5
  • Use of MAO-A inhibitor within past 2 weeks 5

Recurrence Management

• Approximately 40% of patients experience headache recurrence within 24 hours after initial relief with triptans 2, 7
• A second dose of the same medication can effectively treat recurrence 7

By following this evidence-based dosing approach, clinicians can optimize acute migraine treatment while minimizing adverse effects and improving patient outcomes.