What are the first-line medications for an acute migraine attack?

First-Line Medications for Acute Migraine Attack

For mild to moderate migraine attacks, NSAIDs (ibuprofen 400-800mg, naproxen sodium 500-825mg, aspirin 900-1000mg, or diclofenac potassium) are first-line treatment, while triptans are first-line for moderate to severe attacks or when NSAIDs fail. 1, 2

Stratified Treatment Approach

Mild to Moderate Attacks

• NSAIDs are the initial choice with specific evidence-based options including: 1, 2

  • Ibuprofen 400-800mg every 6-8 hours 2
  • Naproxen sodium 500-825mg at onset, repeatable every 2-6 hours (maximum 1.5g/day) 1
  • Aspirin 900-1000mg 2
  • Diclofenac potassium 1

• Combination therapy (acetaminophen + aspirin + caffeine) provides synergistic analgesia when NSAIDs alone are insufficient 1

Moderate to Severe Attacks

• Triptans are first-line for moderate-severe migraine with seven evidence-based options: 1, 2, 3

  • Sumatriptan 25-100mg orally (or 6mg subcutaneous for fastest effect) 2
  • Rizatriptan 1, 3
  • Eletriptan 3
  • Zolmitriptan 1, 3
  • Naratriptan 1, 3
  • Almotriptan 3
  • Frovatriptan 3

• Subcutaneous sumatriptan 6mg provides the highest efficacy (59% pain-free at 2 hours) with fastest onset at 15 minutes, though with higher adverse event rates 1

Route Selection Based on Symptoms

When Nausea/Vomiting Present

• Choose non-oral routes as gastroparesis impairs oral medication absorption: 1, 2

  • Subcutaneous sumatriptan 6mg 1
  • Intranasal sumatriptan 5-20mg or zolmitriptan 1, 4
  • Rectal sumatriptan 4

• Add antiemetics for dual benefit (treat nausea AND provide synergistic analgesia): 1

  • Metoclopramide 10mg IV/oral 1
  • Prochlorperazine 10mg IV/25mg oral 1

Intravenous Options for Severe Attacks

• IV metoclopramide 10mg + IV ketorolac 30mg is the recommended first-line IV combination for severe migraine requiring parenteral treatment 1

• IV prochlorperazine 10mg is equally effective to metoclopramide with comparable efficacy 1

• Intranasal or IV dihydroergotamine (DHE) has good evidence as monotherapy for acute attacks 1, 5

Critical Timing and Frequency Considerations

• Administer treatment as early as possible during the attack while pain is still mild to maximize efficacy 1, 2

• Triptans work best when taken early but NOT during aura phase 2

• Limit acute medication use to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 1, 2

Contraindications and Safety

Triptan Contraindications (Critical to Screen)

• Do not use triptans in patients with: 6

  • Ischemic heart disease or previous myocardial infarction 6
  • Uncontrolled hypertension 1, 2
  • Basilar or hemiplegic migraine 2
  • History of stroke or TIA 1
  • Prinzmetal's angina 6

• Cardiovascular risk assessment required for triptan-naive patients with multiple CV risk factors (age, diabetes, hypertension, smoking, obesity, strong family history of CAD) before first dose 6

NSAID Precautions

• Avoid NSAIDs in: 1
  • Renal impairment (CrCl <30 mL/min) 1
  • Active GI bleeding or history of GI bleeding 1
  • Aspirin/NSAID-induced asthma 1

Medications to Avoid

• Opioids should be reserved only for last-line use when other medications cannot be used, sedation is not a concern, and abuse risk has been addressed—they lead to dependency, rebound headaches, and loss of efficacy 1, 5, 3

• Butalbital-containing compounds should similarly be avoided except as rescue therapy for refractory attacks 1

When to Escalate to Preventive Therapy

• Initiate preventive therapy if: 1
  • Two or more attacks per month with ≥3 days of disability 1
  • Using acute medications more than twice weekly 1
  • Contraindications to acute treatments 1
  • Failure of acute treatments despite optimization 1