From the Guidelines
The most effective management option for acute migraine attacks is to use a combination of medication and non-medication approaches, with ibuprofen and triptans being commonly prescribed, as recommended by the most recent and highest quality study 1.
Medication Approaches
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400-600 mg) or naproxen (500-550 mg) are effective for mild to moderate migraines.
- Triptans, such as sumatriptan (50-100 mg orally, 6 mg subcutaneously, or 20 mg intranasally), are effective for moderate to severe migraines and should be taken early in the attack for maximum effectiveness.
- Antiemetics like metoclopramide (10 mg) or prochlorperazine (10 mg) can help with nausea and may enhance absorption of other medications.
- For patients who don't respond to triptans, dihydroergotamine (DHE) can be used (0.5-1 mg intranasally or 1 mg subcutaneously/intramuscularly).
Non-Medication Approaches
- Resting in a dark, quiet room can help alleviate symptoms.
- Applying cold or warm compresses to the head or neck can help relieve pain.
- Staying hydrated is essential to prevent worsening symptoms.
- Avoiding triggers like bright lights, loud noises, and certain foods during an attack can help prevent worsening symptoms.
- Maintaining a consistent sleep schedule can help prevent worsening symptoms.
Key Considerations
- Patients should be advised to treat acute migraine early in the attack 1.
- If one triptan is ineffective, trying another or a non-steroidal anti-inflammatory drug-triptan combination may be helpful 1.
- Preventive treatments should be considered in children/adolescents with frequent or disabling headaches or medication overuse 1.
From the FDA Drug Label
Sumatriptan tablets, USP are a serotonin (5-HT1B/1D) receptor agonist (triptan) indicated for acute treatment of migraine with or without aura in adults. Single dose of 25 mg, 50 mg, or 100 mg tablet. A second dose should only be considered if some response to the first dose was observed. Maximum dose in a 24-hour period: 200 mg.
The management options for acute migraine attack include:
- Sumatriptan tablets: 25 mg, 50 mg, or 100 mg as a single dose, with a maximum dose of 200 mg in a 24-hour period 2
- A second dose of sumatriptan tablets can be considered if there is some response to the first dose, with at least 2 hours between doses 2
- Additional treatments such as acetaminophen may be allowed 4 to 24 hours after the initial treatment for recurrent headache or as rescue 2
From the Research
Management Options for Acute Migraine Attack
The management options for acute migraine attack can be categorized into several groups, including:
- Migraine-specific medications, such as triptans, which are recommended as first-line treatments for moderate to severe migraine attacks 3, 4
- Migraine-nonspecific medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), which are recommended as first-line treatments for mild to moderate migraine attacks 3, 4
- Antiemetics, which can be used as supplements to alleviate nausea and vomiting 3, 5
- Ergot alkaloids, which can be used as second- or third-line therapy for select patients or for those with refractory migraine 4
- Combination analgesics, which can be used as alternatives for mild to moderate migraine attacks 3
Treatment Strategies
The treatment strategies for acute migraine attack include:
- Stratified care, where the treatment is tailored to the severity of the migraine attack 3, 4
- Taking medication early in the attack, which can help to ensure that the treatment is cost-effective 4
- Using a combination of medications, such as a triptan and a NSAID, which can yield a better efficacy compared with either therapy alone 3, 6
- Limiting the use of acute treatment to a maximum of ten days a month to prevent medication-overuse headache 3
Pharmacologic Treatments
The pharmacologic treatments for acute episodic migraine headache include:
- Triptans, which are recommended as first-line treatments for moderate to severe migraine attacks 3, 4, 6
- NSAIDs, which are recommended as first-line treatments for mild to moderate migraine attacks 3, 4
- Acetaminophen, which is suitable for mild to moderate migraine attacks and remains the first choice for children and pregnant women 3, 4
- Metoclopramide, which can be used as a supplement to alleviate nausea and vomiting 7, 5
- Dexamethasone, which can be used to prevent recurrence of headache 5