What are the outpatient treatment options for migraine headaches?

From the Guidelines

Outpatient treatment of migraine should prioritize acute symptom relief with NSAIDs, triptans, and antiemetics, while also considering preventive medications and lifestyle modifications to improve quality of life and reduce morbidity and mortality.

Key Considerations

• For acute attacks, first-line medications include NSAIDs (ibuprofen 400-800mg or naproxen 500-550mg) and triptans (sumatriptan 50-100mg, rizatriptan 10mg, or zolmitriptan 2.5-5mg) taken at the earliest sign of headache, as recommended by the American College of Physicians 1.
• Antiemetics like metoclopramide 10mg can help with associated nausea, and nonoral triptans with antiemetics should be considered in people having severe nausea or vomiting 1.
• For prevention in patients with frequent migraines (>4 monthly), options include beta-blockers, anticonvulsants, certain antidepressants, and CGRP antagonists, with the goal of reducing frequency and severity of attacks 1.
• Newer treatments include gepants (ubrogepant, rimegepant) for acute attacks and ditans (lasmiditan) for patients with cardiovascular contraindications to triptans, offering alternative options for patients who do not respond to traditional treatments 1.
• Non-pharmacological approaches are also crucial, including trigger identification and avoidance, regular sleep patterns, stress management, and adequate hydration, as these can significantly impact migraine frequency and severity 1.
• Patients should maintain a headache diary to track frequency, severity, triggers, and medication effectiveness, allowing for personalized treatment plans and adjustments as needed.
• Medication overuse should be avoided, with acute treatments limited to 2-3 days per week, to prevent worsening of migraines and improve overall quality of life.

Additional Recommendations

• Consider using CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen 1.
• Lifestyle modifications, including staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, engaging in regular physical activity, managing stress, and pursuing weight loss if applicable, should be emphasized to patients as essential components of migraine management 1.

From the FDA Drug Label

The efficacy of rizatriptan benzoate tablets was established in four multicenter, randomized, placebo-controlled trials. Patients enrolled in these studies were primarily female (84%) and Caucasian (88%), with a mean age of 40 years (range of 18 to 71). Patients were instructed to treat a moderate to severe headache Headache response, defined as a reduction of moderate or severe headache pain to no or mild headache pain, was assessed for up to 2 hours (Study 1) or up to 4 hours after dosing (Studies 2,3 and 4). In all studies, the percentage of patients achieving headache response 2 hours after treatment was significantly greater in patients who received either rizatriptan benzoate 5 mg or 10 mg compared to those who received placebo.

Outpatient treatment of migraine with rizatriptan benzoate tablets is effective.

• The percentage of patients achieving headache response 2 hours after treatment was significantly greater in patients who received either rizatriptan benzoate 5 mg or 10 mg compared to those who received placebo 2.
• Key findings include:
  • 62% of patients achieved headache response with 5 mg dose
  • 71% of patients achieved headache response with 10 mg dose
  • Headache response was defined as a reduction of moderate or severe headache pain to no or mild headache pain 2.

From the Research

Outpatient Treatment of Migraine

• The primary goals of acute migraine therapy are to reduce attack duration and severity 3.
• Current evidence-based therapies for acute migraine attacks include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, NSAID-triptan combinations, dihydroergotamine, non-opioid combination analgesics, and several anti-emetics 3, 4.
• Over-the-counter medications, such as acetaminophen, ibuprofen, naproxen, and aspirin, have shown strong efficacy when used as first-line treatments for mild-to-moderate migraine attacks 3.
• Rizatriptan, a serotonin 5-HT1 receptor agonist, has been demonstrated to be effective in the management of migraine, with a faster onset of action and better relief from pain and nausea compared to sumatriptan 5, 6, 7.
• The efficacy of oral rizatriptan (5 or 10 mg) has been shown to be superior to placebo and comparable to or better than oral sumatriptan in large, well-designed comparative trials 6.
• Rizatriptan 10 mg appears to be more effective than rizatriptan 5 mg, and may provide better relief from pain and nausea, with some evidence of a faster onset of action, compared to oral sumatriptan 6, 7.

Treatment Options

• Acetaminophen and nonsteroidal anti-inflammatory drugs are first-line treatments for mild to moderate migraines 4.
• Triptans, such as rizatriptan and sumatriptan, are first-line treatments for moderate to severe migraines 4.
• Anti-emetics and ergot alkaloids are recommended for use as second- or third-line therapy for select patients or for those with refractory migraine 4.

Considerations

• The pharmacologic properties, potential adverse effects, cost, and routes of administration of migraine treatments vary widely, allowing therapy to be individualized based on the pattern and severity of attacks 4.
• The incidence of adverse events with rizatriptan is similar to that with sumatriptan, but with a lower incidence of chest pain and no clinically significant effects on ECG parameters, heart rate, or blood pressure 6.