What is the recommended dose and duration of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for acute migraine management?

NSAID Dosing and Duration for Acute Migraine

For acute migraine treatment, NSAIDs should be dosed at the onset of headache (ideally when pain is still mild) and can be used for up to 3 consecutive days per attack, but must be limited to no more than twice weekly overall to prevent medication-overuse headache. 1

Specific NSAID Dosing Recommendations

First-Line NSAIDs with Proven Efficacy

• Naproxen sodium: 500-825 mg at migraine onset, can be repeated every 2-6 hours as needed, maximum 1.5 g per day 1
• Ibuprofen: Standard dosing for acute migraine (specific dose not detailed in guidelines, but typically 400-800 mg) 2, 3
• Aspirin: Proven efficacy as monotherapy or in combination with acetaminophen plus caffeine 2, 3
• Diclofenac potassium: Evidence-based option for acute treatment 4, 5

Parenteral NSAID Option

• Ketorolac: 30 mg IV (or 60 mg IM for patients under 65 years) for severe migraine requiring emergency/urgent care treatment, with reduced doses for patients ≥65 years or with renal impairment 1

Duration and Frequency Guidelines

Per-Attack Duration

• NSAIDs can be safely used for up to 3 consecutive days for a single migraine attack 1
• Treatment should begin as early as possible during the attack to improve efficacy 1, 5

Weekly Frequency Limits

• Critical threshold: Limit NSAID use to no more than twice weekly to guard against medication-overuse headache 2, 1, 6
• Medication-overuse headache can result from frequent use of acute medications (more than twice weekly), leading to increasing headache frequency and potentially daily headaches 2, 1

Optimization Strategies

Combination Therapy for Enhanced Efficacy

• Adding an antiemetic (metoclopramide 10 mg or prochlorperazine 25 mg) 20-30 minutes before the NSAID provides synergistic analgesia and improves outcomes compared to NSAID alone 1
• Combination therapy with acetaminophen plus aspirin plus caffeine has proven efficacy when NSAIDs alone are insufficient 2, 3

When to Escalate Beyond NSAIDs

• If NSAIDs fail after 2-3 migraine episodes, escalate to triptan therapy for moderate-to-severe attacks 1, 6
• For patients whose migraine attacks have not responded to NSAIDs, use migraine-specific agents (triptans, DHE) 2

Critical Contraindications and Precautions

Absolute Contraindications

• Renal impairment (creatinine clearance <30 mL/min) 1
• Active GI bleeding or history of GI bleeding 1
• Aspirin/NSAID-induced asthma 1

Relative Contraindications

• Heart disease (use ketorolac with caution) 1
• Uncontrolled hypertension 1

Common Pitfalls to Avoid

The Medication-Overuse Trap

• Do not allow patients to increase frequency of NSAID use in response to inadequate relief, as this creates a vicious cycle of medication-overuse headache 1
• If headaches occur more than 2-3 times per week, transition to preventive therapy rather than increasing acute treatment frequency 1, 6

Timing Errors

• NSAIDs are most effective when taken early in the attack while headache is still mild, not after pain has reached peak intensity 1, 5
• Delayed treatment significantly reduces efficacy 5

Monotherapy Limitations

• Acetaminophen alone lacks evidence for efficacy in migraine and should not be used as monotherapy 2, 3
• Consider combination therapy or escalation to triptans rather than continuing ineffective NSAID monotherapy 1