What are the treatment options for acute migraine?

Acute Migraine Treatment Options

NSAIDs and triptans are the first-line treatments for acute migraine, with selection based on attack severity and patient-specific factors. 1, 2

First-Line Treatment Options

For Mild to Moderate Attacks

• NSAIDs are recommended as first-line therapy with strong evidence supporting acetylsalicylic acid (aspirin), ibuprofen, naproxen sodium, and diclofenac potassium 1, 2
• Over-the-counter NSAIDs with proven efficacy include aspirin, ibuprofen, and diclofenac potassium 2
• Combination analgesics containing caffeine can be effective for mild attacks 2
• Paracetamol (acetaminophen) has less efficacy than NSAIDs but may be used in patients who cannot tolerate NSAIDs 2

For Moderate to Severe Attacks

• Triptans are recommended as first-line treatment for moderate to severe migraine attacks or when NSAIDs fail 1, 2
• Sumatriptan is the most commonly used triptan with multiple formulations available (oral, subcutaneous, intranasal) 3, 4
• Oral sumatriptan 50mg and 100mg doses provide significant pain relief compared to placebo, with NNTs of 6.1 and 4.7 respectively for pain-free at two hours 5
• Subcutaneous sumatriptan shows the greatest efficacy for pain relief but with higher adverse events 3

Combination and Advanced Approaches

• Combining a triptan with an NSAID provides superior efficacy compared to either medication alone 1, 2
• If one triptan is ineffective, trying another triptan may provide relief 1
• Early treatment during the mild pain phase yields better outcomes than treating established attacks with moderate or severe pain 5
• For patients with significant nausea or vomiting, consider non-oral routes of administration or adding antiemetics 1, 2

Third-Line Options for Refractory Migraine

• Ditans (lasmiditan) can be used as a third-line option for refractory migraine 1
• CGRP antagonists (gepants) such as rimegepant and ubrogepant are options for patients who don't respond to or cannot tolerate triptans 1, 2
• Dihydroergotamine (DHE) is suitable for selected patients with refractory migraine 6

Important Considerations and Cautions

• Limit acute medication use to prevent medication overuse headache: ≤15 days/month for NSAIDs, ≤10 days/month for triptans 2
• Avoid opioids and butalbital-containing analgesics for migraine treatment 2
• Sumatriptan is contraindicated in patients with coronary artery disease, uncontrolled hypertension, and those taking MAO-A inhibitors 7
• Caution is needed when using sumatriptan in patients with psychiatric illnesses, especially those treated with SSRIs or SNRIs, due to risk of serotonin syndrome 7, 4
• Adverse events with sumatriptan are generally mild to moderate and transient, with a clear dose-response relationship 5

Special Populations

• Acetaminophen is the safest acute migraine drug during pregnancy 6
• For patients with contraindications to vasoconstricting drugs, options include NSAIDs, combination analgesics, and dopamine antagonists 6

Preventive Treatment Considerations

• Consider preventive therapy for patients with: two or more attacks per month producing disability lasting 3+ days per month; contraindication to or failure of acute treatments; use of acute medication more than twice per week; or presence of uncommon migraine conditions 8, 2

By following these evidence-based recommendations and considering patient-specific factors, clinicians can effectively manage acute migraine attacks and improve patient outcomes.