What is the initial treatment for acute migraine?

Initial Treatment for Acute Migraine

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are the recommended first-line therapy for mild to moderate attacks. 1, 2, 3

First-Line Treatment Options

• NSAIDs with proven efficacy include aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 2, 3
• The combination of acetaminophen plus aspirin plus caffeine is also effective as first-line therapy and has shown significant improvement in critical outcomes with a number needed to treat of 9 for pain freedom at 2 hours 1, 2
• Acetaminophen alone has less efficacy and should only be used in patients who cannot tolerate NSAIDs 2

Treatment Algorithm Based on Migraine Severity

For Mild to Moderate Attacks:

• Start with oral NSAIDs or acetaminophen-aspirin-caffeine combination 1, 2, 3
• Administer early in the headache phase for maximum effectiveness 3, 4
• If inadequate response after 2 hours, consider adding or switching to a triptan 2, 3

For Moderate to Severe Attacks:

• Use migraine-specific agents (triptans, DHE) as first-line therapy 1, 3
• Triptans with good evidence include oral sumatriptan, rizatriptan, naratriptan, and zolmitriptan 1, 5, 6
• Subcutaneous sumatriptan has the fastest onset of action and is particularly useful when rapid relief is needed 5, 6

Special Considerations

• For migraines with significant nausea or vomiting, select a non-oral route of administration (subcutaneous sumatriptan or DHE nasal spray) 1, 2
• Add an antiemetic to treat nausea, even if vomiting is not present 1, 2
• Triptans are most effective when taken early in an attack when headache is still mild, but should not be used during the aura phase 2, 5

Treatment of Refractory Migraine

• If one triptan is ineffective, trying another triptan may provide relief 2, 3
• Consider combining a triptan with an NSAID for superior efficacy in patients with inadequate response to a single agent 3
• Newer options for refractory migraine include gepants (ubrogepant, rimegepant) which have shown moderately robust effects with a number needed to treat of 13 for pain freedom at 2 hours 1, 3
• Lasmiditan (ditan) has demonstrated robust benefits but has significant adverse effects including driving restrictions 1, 3

Important Cautions

• Limit acute treatments to no more than twice weekly to prevent medication overuse headache 3, 4
• Avoid opioids due to questionable efficacy, adverse effects, and risk of dependency 4
• Consider preventive therapy for patients experiencing frequent attacks (≥2 attacks per month) 1, 4

Efficacy Considerations

• Clinical trials show that 60-70% of patients achieve headache response (reduction from moderate/severe to mild/no pain) within 2 hours with triptans compared to 20-40% with placebo 5, 6
• The combination of acetaminophen-aspirin-caffeine has a number needed to treat of 4 for pain relief at 2 hours 1
• Early treatment during the mild pain phase significantly improves outcomes 5, 6