What are the recommended acute medications for migraine treatment?

Acute Medication for Migraine

Start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) or acetaminophen 1000 mg for mild-to-moderate attacks, and immediately escalate to combination therapy with a triptan plus NSAID for moderate-to-severe attacks or when NSAIDs alone fail. 1

First-Line Treatment Algorithm

Mild-to-Moderate Migraine

• Begin with oral NSAIDs or acetaminophen as monotherapy 1
• Specific NSAIDs with strong evidence: aspirin, ibuprofen, naproxen sodium, diclofenac potassium 1
• Ensure adequate dosing before declaring treatment failure 1
• Alternative: combination analgesic containing acetaminophen, aspirin, and caffeine 1

Moderate-to-Severe Migraine

• Initiate combination therapy: triptan PLUS NSAID (or acetaminophen if NSAIDs contraindicated) 1
• This combination is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 2
• Specific triptans with evidence: sumatriptan 50-100 mg, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, naratriptan 1, 3
• Administer as early as possible in the attack while pain is still mild 1, 4

Route Selection Based on Symptoms

• Oral route preferred for most patients 1
• Non-oral routes (subcutaneous, intranasal, suppository) when significant nausea or vomiting present 1, 4
• Subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours) but higher adverse events 2
• Add antiemetic (metoclopramide 10 mg or prochlorperazine 10 mg) for nausea 1, 2

Second-Line Options for Treatment Failure

If combination triptan plus NSAID fails or is contraindicated, consider CGRP antagonists (gepants: rimegepant, ubrogepant, zavegepant) or dihydroergotamine 1

Specific Second-Line Agents

• CGRP antagonists-gepants for patients not responding to triptan-NSAID combination 1
• Dihydroergotamine (intranasal or IV) has good efficacy evidence 1, 2
• Lasmiditan (ditan) reserved for patients failing all other treatments 1

Switching Within Drug Classes

• Failure of one triptan does not predict failure of others—trial a different triptan before abandoning the class 1, 2
• Choice of specific NSAID or triptan based on patient preference for route, cost, and prior response 1

Critical Frequency Limitation

Limit ALL acute migraine medications to maximum 2 days per week (10 days per month) to prevent medication-overuse headache 1, 2

• NSAIDs: ≥15 days/month causes medication-overuse headache 1
• Triptans: ≥10 days/month causes medication-overuse headache 1
• If needing acute treatment more than twice weekly, immediately initiate preventive therapy 2, 4

Medications to Avoid

Do not use opioids or butalbital-containing compounds for acute migraine treatment 1

• Opioids lead to dependency, rebound headaches, and loss of efficacy 2, 4
• Reserve opioids only when all other options exhausted, contraindicated, or abuse risk addressed 2

Emergency/Refractory Setting (IV Cocktail)

For severe attacks requiring parenteral therapy: metoclopramide 10 mg IV PLUS ketorolac 30 mg IV 2, 4

• Metoclopramide provides direct analgesic effects beyond antiemetic properties through dopamine antagonism 2
• Ketorolac has rapid onset with 6-hour duration and minimal rebound risk 2
• Alternative: dihydroergotamine IV for refractory cases 2, 4
• Consider IV corticosteroids for status migrainosus 4

Contraindications Requiring Alternative Approach

Triptans contraindicated in: 3

• Coronary artery disease or vasospasm
• History of stroke or TIA
• Hemiplegic or basilar migraine
• Peripheral vascular disease
• Uncontrolled hypertension
• Wolff-Parkinson-White syndrome

For patients with triptan contraindications: use NSAIDs, acetaminophen, combination analgesics, or dopamine antagonists (metoclopramide, prochlorperazine) 2, 4

Pregnancy and Lactation

• Acetaminophen is safest option during pregnancy 1
• NSAIDs acceptable prior to third trimester 5
• Sumatriptan may be option for selected pregnant patients and is compatible with breastfeeding 6
• Discuss adverse effects of all pharmacologic treatments with patients of childbearing potential 1

Common Pitfalls to Avoid

• Inadequate dosing before declaring treatment failure—ensure maximum recommended doses used 1
• Delayed administration—efficacy highest when treating early while pain still mild 1, 4
• Not combining triptan with NSAID—combination superior to monotherapy 1, 2
• Allowing escalation of acute medication frequency—this creates medication-overuse headache cycle; transition to preventive therapy instead 2, 4
• Using opioids routinely—leads to dependency and worsening headache pattern 1, 4