What is the recommended treatment for an adult patient presenting to an urgent care setting with a migraine?

Acute Migraine Treatment in Urgent Care

For nonpregnant adults presenting to urgent care with moderate to severe migraine, start with a triptan combined with an NSAID (such as sumatriptan 50-100 mg plus naproxen 500 mg), which provides superior pain relief compared to either medication alone. 1

Initial Assessment and Treatment Algorithm

First-Line Approach for Moderate to Severe Migraine

• Combination therapy of a triptan plus an NSAID is the most effective initial treatment, with 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to triptan monotherapy 1
• Specific recommended combinations include sumatriptan (50-100 mg) with naproxen (500 mg) 1
• Alternative NSAIDs include aspirin, celecoxib, diclofenac, or ibuprofen if naproxen is unavailable 1
• Alternative triptans include almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, or zolmitriptan 1

If NSAIDs Are Contraindicated

• Use a triptan combined with acetaminophen 1000 mg for patients who cannot tolerate NSAIDs 1
• This combination shows directionally favorable outcomes compared to acetaminophen alone, though evidence is lower certainty 1

For Patients with Severe Nausea or Vomiting

• Administer metoclopramide 10 mg IV or IM as both an antiemetic and analgesic agent 2
• Consider nonoral triptan formulations (nasal spray, subcutaneous injection) when oral absorption is compromised 1
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain directly 3

Second-Line Options for Refractory Cases

When First-Line Treatment Fails

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant for patients not responding to triptan-NSAID combinations 1, 4
• Dihydroergotamine (DHE): particularly effective in intranasal formulation for refractory migraine 4, 5
• Lasmiditan (ditan): reserve for patients who fail all other treatments 1, 4

Important Contraindications for DHE

• Uncontrolled hypertension, coronary artery disease, or peripheral vascular disease 4
• Recent use (within 24 hours) of triptans 6

Critical Medications to AVOID

Never use opioids or butalbital-containing medications for acute migraine treatment due to risks of dependency, rebound headaches, and medication overuse headache 1, 7

Medication Overuse Headache Prevention

• Limit triptan use to <10 days per month 1
• Limit NSAID/acetaminophen use to <15 days per month 1
• Medication overuse headache develops with headache occurring ≥15 days per month for at least 3 months due to overuse of acute medications 1

Special Population: Pregnant Patients

Safe Options During Pregnancy

• Acetaminophen 1000 mg is first-line for pregnant patients with migraine 3
• Metoclopramide 10 mg is safe and effective for migraine-associated nausea, particularly in second and third trimesters 3
• NSAIDs (ibuprofen) may be used only during the second trimester 3

Medications Contraindicated in Pregnancy

• Triptans have insufficient safety data and should be avoided (sumatriptan may be used sporadically under specialist supervision only) 3
• Ergot alkaloids (DHE) are absolutely contraindicated due to oxytocic properties 3
• CGRP antagonists (gepants) have insufficient safety data 3
• Opioids and butalbital-containing medications should not be used 3

Dosing Specifics

Triptan Dosing

• Sumatriptan oral: 25 mg, 50 mg, or 100 mg as single dose 6
• Maximum 200 mg in 24 hours; separate doses by at least 2 hours 6
• Reduce maximum single dose to 50 mg in patients with mild to moderate hepatic impairment 6

NSAID Dosing

• Naproxen: 500 mg (typically combined with triptan) 1
• Ibuprofen: standard migraine dosing per product labeling 1

Antiemetic Dosing

• Metoclopramide: 10 mg IV, IM, or oral 3, 2
• Prochlorperazine: 25 mg oral or suppository 3

Clinical Pearls for Urgent Care Settings

• Counsel patients to begin treatment as soon as possible after migraine onset to improve efficacy 1
• Provide a quiet, dark environment and ensure adequate hydration with IV fluids 3
• Different triptans within the same class may work when another fails—trial of alternative triptan is reasonable 1
• If episodic migraine occurs frequently (≥2 attacks per month with ≥3 days of disability), consider referral for preventive therapy 1, 4

Discharge Planning

• Prescribe acetaminophen 1000 mg for home use as rescue medication 3
• Avoid prescribing opioids or butalbital-containing medications for home use 3
• Educate patients about medication overuse headache thresholds 1
• Recommend lifestyle modifications: adequate hydration, regular meals, consistent sleep patterns, and trigger identification 1, 4