What are the treatment options for acute migraine management?

Acute Migraine Management

First-Line Treatment: Stratified by Severity

For mild to moderate migraine attacks, start with NSAIDs (aspirin, ibuprofen, naproxen sodium, or diclofenac potassium), while moderate to severe attacks should be treated with triptans as first-line therapy. 1, 2

Mild to Moderate Migraine

• NSAIDs are the first-line choice, with strong evidence supporting aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 2, 3
• Combination therapy of acetaminophen plus aspirin plus caffeine is effective, but acetaminophen alone has limited efficacy and is not recommended as monotherapy 1, 3
• Treat as early as possible during the attack, ideally while pain is still mild, to maximize efficacy 1, 2, 3

Moderate to Severe Migraine

• Triptans are first-line therapy for moderate to severe attacks or when NSAIDs fail 1, 2
• Oral triptans with strong evidence include sumatriptan, rizatriptan, naratriptan, and zolmitriptan 1, 3
• Sumatriptan 100 mg achieves pain-free response at 2 hours in approximately 59% of patients (NNT 4.7) and headache relief in 67% (NNT 3.5) 4
• Subcutaneous sumatriptan provides the fastest relief, with 70-80% achieving headache relief within 1 hour 5, 6

Combination Therapy for Enhanced Efficacy

Combining a triptan with an NSAID provides superior efficacy compared to either agent alone and should be considered for patients with inadequate response to monotherapy. 2, 3

• This combination approach improves outcomes across all efficacy measures 2, 7
• If one triptan is ineffective, trying another triptan may still provide relief 2, 3

Special Considerations: Nausea and Vomiting

For patients with significant early nausea or vomiting, select non-oral routes of administration. 1, 2

• Options include subcutaneous sumatriptan and intranasal dihydroergotamine 1
• Intranasal dihydroergotamine 2 mg achieves headache response in 48-70% of patients at 4 hours 8
• Add antiemetics (metoclopramide or prochlorperazine) not only for vomiting but also for significant nausea 1, 3
• Intravenous metoclopramide may be appropriate as monotherapy for acute attacks, especially when nausea and vomiting are prominent 1

Third-Line Options for Refractory Migraine

For patients who fail all available triptans or have contraindications to their use, consider CGRP antagonists (gepants such as rimegepant or ubrogepant), ditans (lasmiditan), or dihydroergotamine. 1, 2, 3

• Lasmiditan has efficacy comparable to triptans but may cause driving impairment 2
• Gepants are CGRP antagonists that can be used for patients who don't respond to or cannot tolerate triptans 2
• For status migrainosus, systemic steroid therapy is the treatment of choice 1

Critical Warnings and Contraindications

Medication Overuse Headache

• Limit acute treatment to no more than 2 days per week (or 10 days per month for triptans, 15 days per month for NSAIDs) to prevent medication overuse headache 1, 2, 9
• Overuse leads to increasing headache frequency and may present as migraine-like daily headaches 9

Avoid These Medications

• Avoid opioids and butalbital-containing compounds, as they lead to dependency and medication overuse headache 1, 3

Triptan Contraindications

• Triptans are contraindicated in patients with ischemic heart disease, coronary artery vasospasm (Prinzmetal angina), uncontrolled hypertension, stroke, or transient ischemic attack 9, 5
• Perform cardiovascular evaluation in triptan-naïve patients with multiple cardiovascular risk factors before prescribing 9
• Be aware of serotonin syndrome risk when combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors 9

When to Consider Preventive Therapy

Consider preventive therapy if the patient experiences 2 or more attacks per month with disability lasting 3 or more days per month, failure of acute treatments, or use of acute medications more than twice weekly. 1

• First-line preventive agents include propranolol, timolol, amitriptyline, divalproex sodium, and sodium valproate 1, 3