Flunarizine and Propranolol Are NOT Effective for Acute Migraine Attacks
Both flunarizine and propranolol are preventive (prophylactic) medications that reduce the frequency of future migraine attacks—they have no role in treating an acute attack that is already occurring. 1, 2
Why These Medications Do Not Work Acutely
Flunarizine is a calcium channel antagonist used exclusively for migraine prevention, requiring 2–3 months of daily use before clinical benefits become apparent; it does not provide rapid relief during an active attack. 2
Propranolol is a beta-blocker used for migraine prophylaxis at doses of 80–240 mg/day, with efficacy assessed only after 2–3 months of continuous therapy; it has no acute analgesic properties. 1, 3
All research evidence for flunarizine and propranolol demonstrates their effectiveness in reducing the number of migraine attacks over months of treatment, not in aborting an attack once it has started. 4, 5, 6, 7
Evidence-Based Acute Migraine Treatment Algorithm
First-Line for Mild-to-Moderate Attacks
NSAIDs are the recommended first-line therapy: ibuprofen 400–800 mg, naproxen sodium 500–825 mg, or aspirin 1000 mg taken at the onset of pain. 8
Combination therapy with acetaminophen 1000 mg + aspirin 500–1000 mg + caffeine 130 mg provides synergistic analgesia for mild-to-moderate attacks. 8
First-Line for Moderate-to-Severe Attacks
Triptans are first-line for moderate-to-severe migraine: sumatriptan 50–100 mg, rizatriptan 10 mg, eletriptan 40 mg, or zolmitriptan 2.5–5 mg taken early when pain is still mild. 8
Combination of triptan + NSAID is superior to either agent alone, with sumatriptan 50–100 mg plus naproxen 500 mg providing the strongest evidence (130 additional patients per 1,000 achieve sustained pain relief at 48 hours). 8
Route Selection for Severe Nausea/Vomiting
Subcutaneous sumatriptan 6 mg provides the highest efficacy with onset within 15 minutes and 59% achieving complete pain relief by 2 hours. 8
Intranasal sumatriptan 5–20 mg is an alternative when oral administration is not feasible. 8
Parenteral Options for Emergency Settings
IV metoclopramide 10 mg plus IV ketorolac 30 mg is the recommended first-line combination for severe migraine requiring intravenous treatment. 8
IV dihydroergotamine (DHE) 0.5–1.0 mg has good evidence as monotherapy when NSAIDs are contraindicated. 8
Critical Frequency Limitation to Prevent Medication-Overuse Headache
All acute migraine medications must be limited to ≤2 days per week (≤10 days per month) to avoid medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 8
If acute treatment is needed more than twice weekly, preventive therapy must be initiated immediately—this is when flunarizine or propranolol would be appropriate. 1, 2
When to Use Flunarizine or Propranolol (Prevention, Not Acute Treatment)
Indications for Preventive Therapy
- ≥2 migraine attacks per month producing disability lasting ≥3 days 1, 2
- Use of acute medications more than twice per week 1, 2
- Failure of or contraindications to acute treatments 1, 2
First-Line Preventive Medications
Propranolol 80–240 mg/day is a first-line preventive agent with FDA approval and strong evidence for reducing attack frequency. 1, 3
Flunarizine 5–10 mg once daily is an effective second-line preventive option where available, with efficacy comparable to propranolol in reducing migraine frequency over months of treatment. 2, 4, 5, 6, 7
Implementation Strategy for Preventive Therapy
Start propranolol at 80 mg daily and titrate to 160–240 mg daily, allowing 2–3 months at the target dose before assessing efficacy. 3
Flunarizine should be started at 5–10 mg once daily (taken at night), with efficacy assessed after 2–3 months of continuous use. 2
Medications to Absolutely Avoid for Acute Migraine
Opioids (hydrocodone, oxycodone, morphine, codeine, tramadol) are contraindicated because they provide limited efficacy, carry high risk of dependence, and precipitate rebound headaches. 8
Butalbital-containing compounds should be avoided due to high risk of medication-overuse headache and dependency. 8