What is the management of acute migraine (Migraine Headache)?

From the Guidelines

Management of acute migraine involves a stepwise approach starting with simple analgesics and progressing to more specific medications if needed, with the most recent guidelines recommending consideration of preventive treatment in patients who are adversely affected by migraine on ≥2 days per month despite optimized acute treatment 1. For mild to moderate migraines, first-line treatment includes NSAIDs such as ibuprofen (400-600mg) or naproxen (500-550mg), or acetaminophen (1000mg) 1. These should be taken at the first sign of headache for maximum effectiveness.

• Key considerations for acute migraine management include:
  • Early treatment with simple analgesics
  • Progression to more specific medications like triptans for moderate to severe migraines
  • Use of antiemetics for nausea and vomiting
  • Combination therapy for enhanced efficacy
  • Rescue treatments for status migrainous or refractory cases
  • Monitoring for medication overuse headache
• Preventive therapy should be considered if acute treatments fail repeatedly, with beta blockers, topiramate, or candesartan as first-line medications, and CGRP monoclonal antibodies as third-line medications 1.
• Patient education on the control of acute attacks and preventive therapy is crucial, with engagement in the formulation of a management plan and regular reevaluation of therapy 1.

From the FDA Drug Label

The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. In all 3 trials, the percentage of patients achieving headache response 2 and 4 hours after treatment was significantly greater among patients receiving sumatriptan tablets at all doses compared with those who received placebo The results from the 3 controlled clinical trials are summarized in Table 2. For patients with migraine-associated nausea, photophobia, and/or phonophobia at baseline, there was a lower incidence of these symptoms at 2 hours (Trial 1) and at 4 hours (Trials 1,2, and 3) following administration of sumatriptan tablets compared with placebo

Management of Acute Migraine with sumatriptan (PO) is effective.

• The medication has been shown to be effective in reducing headache severity from moderate or severe pain to mild or no pain.
• Key benefits include a significant reduction in headache response at 2 and 4 hours after treatment, as well as a lower incidence of migraine-associated symptoms such as nausea, photophobia, and phonophobia.
• Dosing: doses of 25,50, and 100 mg were compared with placebo, with no statistically significant differences between the 50 mg and 100 mg dose groups in any trial 2.

From the Research

Management of Acute Migraine

• The management of acute migraine involves the use of various medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, and antiemetics 3, 4, 5.
• NSAIDs, such as ibuprofen, naproxen sodium, and diclofenac potassium, are effective for mild to moderate migraine attacks 3, 4.
• Triptans, such as sumatriptan, rizatriptan, and eletriptan, are effective for moderate to severe migraine attacks 3, 4, 6.
• Antiemetics, such as prochlorperazine, can be used to alleviate nausea and vomiting associated with migraine attacks 4, 5.

Treatment Strategies

• A stratified treatment approach can be used, where patients with mild to moderate migraine attacks are treated with oral NSAIDs, and those with moderate to severe attacks are treated with oral or nasal spray triptans 4, 5.
• Combination therapy, such as sumatriptan plus naproxen, can be effective for acute migraine treatment 6.
• Parenteral steroid and fluid supply can be used to treat status migrainosus, a complication of migraine characterized by a persistent debilitating migraine attack lasting for more than 72 hours 7.

Special Considerations

• Acetaminophen is the safest acute migraine drug during pregnancy, and acetaminophen with codeine is also an option 3.
• Sumatriptan may be an option during pregnancy for selected patients and is compatible with breast-feeding 3.
• Opioids and combination analgesics containing opioids should not be used routinely for acute migraine treatment due to the risk of serious adverse events 3, 4, 5.