What is the best treatment for acute migraines?

Best Treatment for Acute Migraines

For mild to moderate migraine attacks, NSAIDs (ibuprofen, naproxen sodium, aspirin, or diclofenac potassium) are first-line treatment; for moderate to severe attacks or when NSAIDs fail, triptans are first-line therapy, with combination triptan plus NSAID providing superior efficacy for refractory cases. 1, 2

Treatment Algorithm by Attack Severity

Mild to Moderate Attacks

• NSAIDs are the initial treatment of choice with strong evidence supporting aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 2
• The combination of acetaminophen plus aspirin plus caffeine is effective, whereas acetaminophen alone is ineffective 3
• Administer medication as early as possible during the attack to maximize efficacy 2

Moderate to Severe Attacks

• Triptans are first-line therapy with good evidence for oral naratriptan, rizatriptan, sumatriptan, and zolmitriptan 3, 1
• Subcutaneous sumatriptan provides the highest efficacy (59% complete pain relief at 2 hours) with the most rapid onset of action, though with higher adverse event rates 3, 1
• Intranasal sumatriptan (5-20mg) is particularly useful for patients with significant nausea or vomiting 1
• Triptans should be taken early in the attack while headache is still mild to optimize effectiveness 1

Refractory or Inadequate Response

• Combination therapy with a triptan plus NSAID provides superior efficacy compared to either agent alone 2
• If one triptan fails, try a different triptan as failure of one does not predict failure of others 1
• Intravenous metoclopramide (10 mg) plus ketorolac (30 mg) is recommended as first-line IV combination therapy for severe attacks requiring parenteral treatment 1

Second-Line Options

• Intranasal dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy 3, 4
• Antiemetics, particularly IV metoclopramide (10 mg) or prochlorperazine (10 mg), are appropriate as monotherapy especially when nausea and vomiting are prominent 3, 1
• Metoclopramide provides synergistic analgesia beyond just treating nausea 1

Third-Line Options for Refractory Migraine

• Ditans (lasmiditan) offer efficacy comparable to triptans but may cause driving impairment 2
• Gepants (rimegepant, ubrogepant) are CGRP antagonists for patients who don't respond to or cannot tolerate triptans 2

Critical Contraindications and Cautions

• Triptans are contraindicated in patients with ischemic heart disease, basilar or hemiplegic migraine, uncontrolled hypertension, or history of stroke/TIA 3, 5
• Patients with multiple cardiovascular risk factors (age, diabetes, hypertension, smoking, obesity, strong family history of CAD) should have cardiovascular evaluation before receiving triptans 5
• Limit acute medication use to no more than twice weekly to prevent medication-overuse headache, which presents as increasing headache frequency progressing to daily headaches 3, 1, 2
• If using acute medications more than 2 days per week, initiate preventive therapy 1

Medications to Avoid

• Opioids should be reserved only for cases where other medications cannot be used, sedation is not a concern, and abuse risk has been addressed 3, 1
• Butorphanol nasal spray has the best evidence among opioids, but these agents can lead to dependency, rebound headaches, and loss of efficacy 3, 1
• Intravenous corticosteroids and intranasal lidocaine are not effective for acute migraine 3

Status Migrainosus (Severe Continuous Migraine)

• Systemic corticosteroids are the treatment of choice for status migrainosus (migraine lasting up to one week) 6
• Initial management includes IV fluids, IV corticosteroids, and antiemetic therapy 6
• If inadequate response within 1-2 hours, add parenteral NSAIDs such as ketorolac 6
• Reserve opioids only for cases not responding to above measures 6

Common Pitfalls

• Do not wait for headache to become severe before treating—early administration significantly improves efficacy 1, 2
• Approximately 40% of patients experience headache recurrence within 24 hours after initial triptan response, which can be effectively treated with a second dose 3, 7
• Do not allow patients to increase frequency of acute medication use in response to treatment failure, as this creates medication-overuse headache; instead transition to preventive therapy 1
• Chest symptoms occur in 3-5% of triptan users but true ischemic events are rare in appropriately selected patients 3