What medication to administer as needed (prn) for migraine treatment?

From the Guidelines

For migraine pain relief on an as-needed (PRN) basis, NSAIDs like ibuprofen (400-600mg) or naproxen sodium (500-550mg) are first-line options for mild to moderate attacks, as they have the most consistent evidence for efficacy 1. When considering treatment options, it's essential to evaluate the severity of the migraine and the patient's medical history.

• For mild to moderate migraines, NSAIDs such as ibuprofen or naproxen sodium are recommended due to their effectiveness and favorable tolerability 1.
• For more severe migraines, triptans like sumatriptan (50-100mg orally, 6mg subcutaneously, or 20mg intranasally) are effective by targeting serotonin receptors to constrict blood vessels and reduce inflammation 1.
• Combination medications like acetaminophen/aspirin/caffeine (Excedrin Migraine) can also be effective for some patients 1.
• Anti-nausea medications such as metoclopramide (10mg) or prochlorperazine (10mg) may help with associated symptoms, and should not be restricted to patients who are vomiting or likely to vomit, as nausea itself is a disabling symptom of migraine 1. It's crucial to educate patients to take medication at the first sign of migraine for best results, rest in a dark, quiet room, and apply cold compresses. If PRN medications fail to provide relief or if migraines occur frequently (more than 4 days per month), preventive therapy should be considered to reduce the frequency and severity of migraines 1. Overuse of PRN medications (more than 10-15 days per month) can lead to medication overuse headaches, so monitoring frequency of use is important.

From the FDA Drug Label

The maximum recommended single dose is 40 mg. In controlled clinical trials, single doses of 20 mg and 40 mg were effective for the acute treatment of migraine in adults If the migraine has not resolved by 2 hours after taking eletriptan hydrobromide tablets, or returns after transient improvement, a second dose may be administered at least 2 hours after the first dose. The maximum daily dose should not exceed 80 mg

For a patient with migraine, eletriptan can be given as needed (prn). The recommended dose is:

• Initial dose: 20 mg or 40 mg
• Second dose (if needed): 20 mg or 40 mg, at least 2 hours after the first dose
• Maximum daily dose: 80 mg 2

From the Research

Acute Migraine Treatment Options

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen sodium, diclofenac potassium, and acetylsalicylic acid are effective for acute migraine treatment 3
• Triptans, including sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, and naratriptan, are also suitable for acute migraine treatment 3, 4, 5
• Dihydroergotamine (DHE) is an option for selected patients 3, 6
• Antiemetic drugs can be added as necessary 3
• 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

Treatment Strategies

• The acetaminophen-NSAID strategy is suitable for patients with mild to moderate migraine attacks 3
• The triptan strategy is suitable for patients with severe attacks and for those with moderate attacks who do not respond well to NSAIDs 3
• Refractory migraine strategies may be useful for patients who do not respond well to NSAIDs or triptans alone, and include using triptans and NSAIDs simultaneously, DHE, and rescue medications 3

Comparative Efficacy of Triptans

• Standard dose triptans relieved headaches within 2 hours in 42 to 76% of patients, and 2-hour sustained freedom from pain was achieved for 18 to 50% of patients 5
• Among individual triptans, sumatriptan subcutaneous injection, rizatriptan ODT, zolmitriptan ODT, and eletriptan tablets were associated with the most favorable outcomes 5
• Triptans are effective for migraine relief, with standard dose triptans associated with better outcomes than ergots, and most triptans associated with equal or better outcomes compared with NSAIDs, ASA, and acetaminophen 5, 6