What are the treatment options for acute migraine management?

Acute Migraine Management

First-Line Treatment Algorithm

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg), and for moderate to severe attacks, use oral triptans (sumatriptan 50-100 mg, rizatriptan 10 mg, or zolmitriptan 2.5-5 mg) combined with an NSAID for superior efficacy. 1, 2

Stratified Treatment by Attack Severity

Mild to Moderate Attacks:

• NSAIDs are the recommended first-line therapy, including aspirin, ibuprofen, naproxen sodium, or diclofenac potassium 1, 2
• Combination therapy with acetaminophen 1000 mg + aspirin 1000 mg + caffeine provides synergistic analgesia when NSAIDs alone are insufficient 1, 2
• Administer treatment as early as possible during the attack, ideally while pain is still mild, to maximize efficacy 1, 2

Moderate to Severe Attacks:

• Oral triptans are first-line therapy, with sumatriptan 50-100 mg, rizatriptan 10 mg, naratriptan 2.5 mg, or zolmitriptan 2.5-5 mg as evidence-based options 1, 2
• The combination of triptan + NSAID is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1
• Sumatriptan 100 mg provides pain-free response in approximately 59-62% of patients at 2 hours versus 17-27% with placebo 3
• Sumatriptan 50 mg is equally effective as 100 mg for most patients and offers better tolerability 4

Non-Oral Routes for Severe Presentations

When significant nausea or vomiting is present early in the attack, select non-oral routes:

• Subcutaneous sumatriptan 6 mg is the most effective and rapidly acting option, providing pain relief in 70-82% of patients within 15 minutes and complete pain relief in 59% by 2 hours 1, 5
• Intranasal sumatriptan 5-20 mg or intranasal dihydroergotamine (DHE) are alternatives 1, 2

Parenteral Treatment for Emergency Department or Urgent Care

For severe attacks requiring IV treatment, use metoclopramide 10 mg IV + ketorolac 30 mg IV as first-line combination therapy, providing rapid pain relief while minimizing rebound headache risk 1, 6

• Prochlorperazine 10 mg IV is equally effective as metoclopramide and may be substituted 1, 6
• Both antiemetics provide direct analgesic effects through central dopamine receptor antagonism, independent of their antiemetic properties 1
• Ketorolac has rapid onset with approximately 6 hours duration and minimal rebound headache risk 1

Antiemetic Therapy

Antiemetics should not be restricted to patients who are vomiting—nausea itself is one of the most disabling symptoms and warrants treatment 7

• Metoclopramide or prochlorperazine can be used as monotherapy for acute attacks, especially when nausea is prominent 1, 2
• Adding an antiemetic 20-30 minutes before oral migraine medication provides synergistic analgesia and improves outcomes 1

Critical Frequency Limitation to Prevent Medication-Overuse Headache

Limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which can lead to daily headaches and increasing attack frequency 1, 2, 6

• NSAIDs should be limited to <15 days/month and triptans to <10 days/month 6
• If patients require acute treatment more than twice weekly, initiate preventive therapy immediately 1, 6

Indications for Preventive Therapy

Consider preventive therapy if the patient experiences:

• Two or more attacks per month producing disability lasting 3 or more days 7, 2
• Use of acute medications more than twice per week 7, 2
• Contraindication to or failure of acute treatments 7, 2
• Uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction) 7

First-line preventive agents include:

• Propranolol 80-240 mg/day or timolol 20-30 mg/day 7, 2
• Amitriptyline 30-150 mg/day 7, 2
• Divalproex sodium 500-1500 mg/day or sodium valproate 800-1500 mg/day 7, 2

Medications to Avoid

Avoid opioids and butalbital-containing compounds for acute migraine treatment, as they lead to dependency, medication-overuse headache, and eventual loss of efficacy 1, 2

• Opioids should only be reserved for cases where other medications cannot be used, sedation is not a concern, and abuse risk has been addressed 1

Contraindications to Triptans

Triptans are contraindicated in patients with:

• Ischemic heart disease, coronary artery vasospasm, or previous myocardial infarction 3
• Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathways 3
• History of stroke, transient ischemic attack, hemiplegic or basilar migraine 3
• Peripheral vascular disease or ischemic bowel disease 3
• Uncontrolled hypertension 3
• Recent use (within 24 hours) of another triptan or ergotamine-containing medication 3
• Concurrent or recent (past 2 weeks) use of MAO-A inhibitors 3

Common Pitfalls to Avoid

• Do not delay treatment—early administration during mild pain phase gives significantly better outcomes than treating established moderate or severe pain 1, 8
• Do not allow patients to increase frequency of acute medication use in response to treatment failure—this creates a vicious cycle of medication-overuse headache; instead transition to preventive therapy 1
• Do not assume failure of one triptan predicts failure of others—if one triptan fails, try a different triptan before abandoning the class 1
• Approximately 40% of patients experience headache recurrence within 24 hours—a second dose of the same medication can be given at least 2 hours after the first dose, with a maximum of 200 mg sumatriptan in 24 hours 3, 9, 5