What is the best treatment for acute migraine in an urgent care setting without intravenous (IV) therapy?

Acute Migraine Treatment Without IV Access in Urgent Care

For acute moderate to severe migraine in urgent care without IV access, start with oral combination therapy of a triptan (sumatriptan 100 mg or 50 mg) plus an NSAID (naproxen 500-825 mg or ibuprofen 400-800 mg), administered as early as possible after headache onset. 1

First-Line Oral Combination Therapy

The American College of Physicians recommends combination therapy with a triptan and an NSAID or acetaminophen as the most effective non-IV approach for moderate to severe migraine. 1 This provides superior efficacy compared to monotherapy and should be initiated immediately when pain is still mild if possible. 1, 2

Specific Dosing Recommendations

Oral Triptan Options:

• Sumatriptan 50-100 mg is the most studied and cost-effective option, with the 100 mg dose providing pain-free response in approximately 28% of patients at 2 hours (NNT 6.1) compared to 11% with placebo 3, 4
• The 50 mg dose offers the best balance of efficacy to tolerability, though many patients require and tolerate the 100 mg dose well 5
• Alternative triptans (rizatriptan, eletriptan, naratriptan, zolmitriptan) can be substituted based on individual response and cost 1

NSAID Component:

• Naproxen sodium 500-825 mg at onset, can repeat every 2-6 hours (maximum 1.5 g/day) 2
• Ibuprofen 400-800 mg is an acceptable alternative 2
• Limit NSAID use to <15 days per month to prevent medication overuse headache 6

Add Antiemetic for Enhanced Efficacy

Administer metoclopramide 10 mg orally or prochlorperazine 25 mg orally 20-30 minutes before the triptan-NSAID combination. 2 This provides synergistic analgesia beyond just treating nausea, as these dopamine antagonists have direct analgesic effects for migraine through central mechanisms. 2

Key Antiemetic Considerations:

• Metoclopramide and prochlorperazine are equally effective for migraine pain relief, not just nausea control 2
• Prochlorperazine has a more favorable side effect profile (21% adverse events vs 50% with chlorpromazine) 2
• Both should be limited to no more than twice weekly to prevent medication overuse headache 2

Alternative Non-Oral Routes When Oral Route Compromised

If significant nausea/vomiting prevents oral administration:

Intranasal Options:

• Sumatriptan nasal spray 20 mg (NNT 3.5 for headache relief at 2 hours) 7
• Zolmitriptan nasal spray 5 mg 2
• Intranasal administration provides faster onset than oral but slower than subcutaneous 7

Subcutaneous Option (if available in urgent care):

• Sumatriptan 6 mg subcutaneous is the most effective and rapidly acting option, providing pain-free response in 59% at 2 hours (NNT 2.3) with relief beginning within 15 minutes 2, 7
• This is the highest efficacy route but has higher adverse event rates 7

Rectal Option:

• Prochlorperazine 25 mg suppository for severe nausea 2
• Sumatriptan 25 mg rectal (NNT 2.4 for headache relief) if oral/intranasal routes fail 7

Second-Line Options for Treatment Failure

If the patient has already tried and failed adequate doses of triptan-NSAID combination:

CGRP Antagonists (Gepants):

• Rimegepant, ubrogepant, or zavegepant 1, 8
• These are appropriate when combination therapy provides inadequate response 1

Dihydroergotamine (DHE):

• Intranasal DHE has good evidence for efficacy when first-line treatments fail 1, 2

Critical Medications to AVOID

Never use opioids or butalbital-containing medications for acute migraine in urgent care. 1, 2 These lead to:

• Medication overuse headache and dependency 2
• Rebound headaches with increasing frequency 2
• Loss of efficacy over time 2

Medication Overuse Prevention

Limit all acute migraine treatments to no more than 2 days per week (or 10 days per month for triptans, 15 days per month for NSAIDs). 1, 6 Exceeding this frequency creates medication overuse headache, transforming episodic migraine into chronic daily headache. 1

If the patient requires acute treatment more frequently, they need preventive therapy rather than more frequent acute treatment. 6

Timing and Rescue Dosing

• Administer treatment as early as possible when pain is still mild for maximum efficacy 1, 3
• A second dose of triptan can be given if there was some response to the first dose, separated by at least 2 hours 3
• Maximum sumatriptan dose is 200 mg in 24 hours 3
• Additional rescue medication can be offered 4-24 hours after initial treatment for recurrent headache 3

Special Contraindications to Screen For

Before prescribing triptans, ensure the patient does NOT have: 3

• History of coronary artery disease or vasospasm
• Uncontrolled hypertension
• History of stroke or TIA
• Peripheral vascular disease
• Recent (within 24 hours) use of another triptan or ergot medication
• Recent (within 2 weeks) use of MAO inhibitor
• Severe hepatic impairment (maximum 50 mg sumatriptan if mild-moderate impairment) 3

When to Consider Preventive Therapy

If this patient has frequent migraines (≥2 days per month) or requires acute treatment more than twice weekly, they need preventive medication rather than relying solely on acute treatment. 6 This should be addressed at follow-up, not in the urgent care setting.