What is the best medication to treat acute migraine headache?

From the Guidelines

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy for treating acute migraine headache, with the most consistent evidence existing for aspirin, ibuprofen, naproxen sodium, tolfenamic acid, and the combination agent acetaminophen plus aspirin plus caffeine. According to the study published in the Annals of Internal Medicine 1, NSAIDs are recommended as the initial treatment for most migraine sufferers. The study also notes that triptans, such as oral naratriptan, rizatriptan, and zolmitriptan, as well as oral and subcutaneous sumatriptan, are effective for patients whose migraine attack has not responded to NSAIDs 1.

Key Points to Consider

• NSAIDs, such as ibuprofen (400-600mg) or naproxen sodium (500-550mg), can be effective for milder migraines or used alongside triptans.
• Acetaminophen combined with caffeine and aspirin can also help alleviate migraine symptoms.
• Triptans, such as sumatriptan, rizatriptan, and zolmitriptan, are effective for treating acute migraine attacks, but should be avoided in patients with cardiovascular disease, uncontrolled hypertension, or hemiplegic migraine.
• For patients with nausea and vomiting, a nonoral route of administration, such as a nasal spray or injection, may be necessary.
• Preventive medications, such as propranolol or amitriptyline, may be considered for patients with frequent migraines (more than 4 days monthly) 1.

Important Considerations

• The choice of medication should be based on the individual patient's needs and medical history.
• Patients should be evaluated for the use of preventive therapy if they experience frequent or severe migraines.
• The study published in the Annals of Internal Medicine 1 provides evidence for the efficacy and safety of various medications for the acute treatment of migraine, including NSAIDs, triptans, and ergotamines.

From the FDA Drug Label

The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. In all 3 trials, the percentage of patients achieving headache response 2 and 4 hours after treatment was significantly greater among patients receiving sumatriptan tablets at all doses compared with those who received placebo

The best medication to treat acute migraine headache is sumatriptan (PO), as it has been shown to be effective in achieving headache response in clinical trials 2.

• Key findings:
  • Sumatriptan tablets were effective in treating migraine headaches in 3 clinical trials.
  • The percentage of patients achieving headache response was significantly greater with sumatriptan compared to placebo.
  • Doses of 25,50, and 100 mg were compared, with no significant differences between the 50 and 100 mg dose groups.
• Important consideration: The efficacy of other medications, such as eletriptan, is not directly comparable based on the provided information 3.

From the Research

Acute Migraine Treatment Options

The best medication to treat acute migraine headache depends on various factors, including the severity of the headache, patient-specific clinical features, and the presence of contraindications to specific medications.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen sodium, diclofenac potassium, and acetylsalicylic acid are effective for mild to moderate migraine attacks 4, 5.
• Triptans, including sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, and naratriptan, are suitable for severe attacks and for patients who do not respond well to NSAIDs 4, 5, 6, 7, 8.
• Dihydroergotamine (DHE) is also an option for selected patients 4, 5.
• Antiemetic drugs can be added as necessary to treat nausea and vomiting associated with migraine attacks 4, 5.

Treatment Strategies

Available acute medications can be organized into four treatment strategies:

• The acetaminophen-NSAID strategy is suitable for patients with attacks of mild to moderate severity 4, 5.
• The triptan strategy is suitable for patients with severe attacks and for those with attacks of moderate severity who do not respond well to NSAIDs 4, 5.
• The refractory migraine strategies may be useful for patients who do not respond well to NSAIDs or triptans alone and include using triptans and NSAIDs simultaneously in combination, DHE, and rescue medications 4, 5.
• Strategies for patients with contraindications to vasoconstricting drugs include use of NSAIDs, combination analgesics, and dopamine antagonists 4, 5.

Special Considerations

• Acetaminophen is the safest acute migraine drug during pregnancy, and acetaminophen with codeine is also an option 4.
• Sumatriptan may be an option during pregnancy for selected patients and is compatible with breast-feeding 4.
• In chronic migraine, it is particularly important that medication overuse is eliminated or avoided 5.