What are the first line treatment options for acute migraine?

Acute Migraine Treatment

For acute migraine treatment, start with NSAIDs (ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg) as first-line therapy for mild-to-moderate attacks, and escalate to triptans (sumatriptan 50-100 mg, rizatriptan, or zolmitriptan) for moderate-to-severe attacks or when NSAIDs fail. 1, 2

First-Line Treatment: NSAIDs

Use NSAIDs as the initial treatment for all migraine attacks unless contraindicated. 1

• Acetylsalicylic acid (aspirin), ibuprofen, and diclofenac potassium have the strongest evidence for first-line use in acute migraine 1
• Paracetamol (acetaminophen) has less efficacy and should only be used in patients intolerant of NSAIDs 1
• Administer NSAIDs early in the attack when pain is still mild for maximum effectiveness 1, 2
• Specific dosing: ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg at onset 2, 3

Second-Line Treatment: Triptans

Escalate to triptans when NSAIDs provide inadequate relief or for moderate-to-severe attacks. 1

• All triptans have well-documented effectiveness, with oral sumatriptan 50-100 mg, rizatriptan, and zolmitriptan having the best evidence 1, 2, 4
• Triptans are most effective when taken early in the attack while headache is still mild 1
• Do not use triptans during the aura phase - there is no evidence supporting this practice 1
• If one triptan fails, try others, as failure of one does not predict failure of another 1, 2

Route Selection for Triptans

• Oral triptans (50-100 mg sumatriptan): Standard route for most patients, with 61-62% achieving headache response at 2 hours 4
• Subcutaneous sumatriptan 6 mg: Most effective formulation with 59% achieving complete pain relief by 2 hours and fastest onset (15 minutes), but highest adverse event rate 1, 5, 6
• Intranasal sumatriptan (5-20 mg): Useful for patients with significant nausea/vomiting or rapid progression to peak intensity 2, 7

Combination Therapy for Enhanced Efficacy

Combine triptans with fast-acting NSAIDs (naproxen sodium, ibuprofen lysine, or diclofenac potassium) to prevent relapse and improve outcomes. 1, 2

• The combination of sumatriptan 50-100 mg PLUS naproxen sodium 500 mg is superior to either agent alone 2
• This strategy addresses the 40% of patients who experience symptom recurrence within 48 hours 1, 2

Third-Line Treatment

If all available triptans fail after adequate trial (no response in at least three consecutive attacks) or are contraindicated, consider ditans (lasmiditan) or gepants. 1

• Availability of these agents is currently very limited 1
• Lasmiditan users should not operate machinery for at least 8 hours after intake 1

Adjunct Medications

Add prokinetic antiemetics for nausea and vomiting during attacks. 1

• Domperidone or metoclopramide (10 mg) are useful oral adjuncts 1
• Metoclopramide provides synergistic analgesia beyond antiemetic effects through central dopamine receptor antagonism 2
• Prochlorperazine (10 mg) is equally effective and has a more favorable side effect profile than chlorpromazine 2

Medications to Avoid

Never use oral ergot alkaloids, opioids, or barbiturates for acute migraine treatment. 1

• Oral ergot alkaloids are poorly effective and potentially toxic 1
• Opioids and barbiturates have questionable efficacy, considerable adverse effects, and risk of dependency 1, 2

Critical Frequency Limitation

Strictly limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache (MOH). 1, 2

• Frequent use (>2 days/week) risks development of MOH, leading to daily headaches 1, 2
• If patients require acute treatment more than twice weekly, initiate preventive therapy immediately 8, 2

Treatment Algorithm by Attack Severity

Mild-to-Moderate Attacks

1. Start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) 1, 2
2. Add antiemetic if nausea present (metoclopramide 10 mg) 1, 2
3. If inadequate response after 2-3 attacks, escalate to triptan 2

Moderate-to-Severe Attacks

1. Start with triptan (sumatriptan 50-100 mg) PLUS NSAID (naproxen 500 mg) 2
2. Add antiemetic if needed 1
3. If oral route problematic due to vomiting, use subcutaneous sumatriptan 6 mg 1, 5

Refractory Attacks

1. Try different triptan if first one fails 1, 2
2. Consider subcutaneous sumatriptan 6 mg for rapid relief 1, 5
3. If all triptans fail, escalate to ditans or gepants 1

Common Pitfalls to Avoid

• Waiting until pain is severe before treating - early treatment when pain is mild significantly improves efficacy 1, 2, 4
• Repeating the same ineffective triptan - switch to a different triptan after 2-3 failed attempts 1, 2
• Using acute medications more than 2 days per week - this creates MOH and worsens migraine frequency 1, 2
• Failing to initiate preventive therapy when patients need acute treatment frequently 8, 2