What is the recommended acute treatment for an adult with an acute migraine attack, including first‑line triptans, anti‑emetics, NSAIDs, and alternatives for contraindications such as uncontrolled hypertension, cardiovascular disease, pregnancy, or drug allergies?

Acute Migraine Treatment

First-Line Treatment Algorithm

For mild-to-moderate migraine attacks, start with NSAIDs (ibuprofen 400–800 mg, naproxen sodium 500–825 mg, or aspirin 1000 mg) or acetaminophen 1000 mg; for moderate-to-severe attacks or when NSAIDs fail after 2–3 episodes, escalate immediately to a triptan (sumatriptan 50–100 mg, rizatriptan 10 mg, or eletriptan 40 mg). 1, 2

Specific NSAID Dosing

• Ibuprofen: 400–800 mg at onset, repeat every 6 hours as needed 1, 3
• Naproxen sodium: 500–825 mg at onset, repeat every 8–12 hours as needed 1, 3
• Aspirin: 1000 mg at onset 1, 3
• Combination therapy: Acetaminophen 1000 mg + aspirin 500–1000 mg + caffeine 130 mg provides synergistic benefit 1, 4

Triptan Selection and Dosing

• Sumatriptan: 50–100 mg oral (most evidence), 6 mg subcutaneous (fastest onset—15 minutes, 70–82% response rate), or 5–20 mg intranasal 1, 5, 3
• Rizatriptan: 10 mg oral (fastest oral triptan, peak at 60–90 minutes) 1, 3
• Eletriptan: 40 mg oral (reportedly more effective with fewer adverse effects than sumatriptan) 1, 3
• Zolmitriptan: 2.5–5 mg oral or nasal spray 1, 3
• Naratriptan: longest half-life, may reduce recurrence 1, 3

Combination Therapy (Strongest Evidence)

The combination of a triptan PLUS an NSAID (e.g., sumatriptan 50–100 mg + naproxen 500 mg) is superior to either agent alone, yielding 130 additional patients per 1000 who achieve sustained pain relief at 48 hours. 1

• This combination should be used for moderate-to-severe attacks or when monotherapy fails 1, 3
• Number-needed-to-treat for headache relief at 2 hours is 3.5 1

Antiemetics (Adjunctive and Monotherapy)

Metoclopramide 10 mg IV or prochlorperazine 10 mg IV provide direct analgesic effects beyond treating nausea and should be given 20–30 minutes before or with NSAIDs/triptans for synergistic benefit. 1, 3

• Metoclopramide is effective as monotherapy for acute attacks, especially when nausea/vomiting are prominent 1
• Prochlorperazine has comparable efficacy to metoclopramide with a more favorable side-effect profile (21% vs 50% adverse events) 1
• Both agents are contraindicated in pheochromocytoma, seizure disorders, and GI obstruction 1

Parenteral Options for Severe Attacks

IV "Migraine Cocktail"

Metoclopramide 10 mg IV + ketorolac 30 mg IV is the recommended first-line parenteral combination for severe migraine in urgent care settings. 1

• Ketorolac provides rapid onset with ~6 hours duration and minimal rebound risk 1
• Reduce ketorolac to 15 mg IV in patients ≥65 years or with renal impairment 1

Subcutaneous Sumatriptan

Subcutaneous sumatriptan 6 mg provides the highest efficacy among all triptan routes (59% pain-free at 2 hours, onset within 15 minutes) and should be used for rapidly escalating attacks or when oral routes fail. 1, 5, 3

Dihydroergotamine (DHE)

• Intranasal or IV DHE has good evidence as monotherapy for acute attacks 1, 3
• Contraindicated with concurrent triptan use (24-hour washout required), beta-blockers, uncontrolled hypertension, coronary artery disease, pregnancy, and sepsis 1, 5

Alternative Agents (Second-Line)

CGRP Antagonists (Gepants)

Ubrogepant 50–100 mg or rimegepant are third-line options for patients who do not tolerate or have inadequate response to triptan + NSAID combinations. 1

• No vasoconstriction—safe in cardiovascular disease, uncontrolled hypertension, or cerebrovascular disease 1
• Limit to ≤8 migraine attacks per 30 days to prevent medication-overuse headache 1

Ditans (Lasmiditan)

Lasmiditan 50–200 mg is a 5-HT1F agonist without vasoconstrictor activity, making it safe for cardiovascular disease, but patients must not drive for ≥8 hours due to CNS effects. 1

Contraindications to Triptans and Ergots

Triptans and DHE are absolutely contraindicated in:

• Ischemic heart disease, previous myocardial infarction, or coronary artery vasospasm 1, 5
• Uncontrolled hypertension 1, 5
• Cerebrovascular disease, history of stroke or TIA 1
• Basilar or hemiplegic migraine 1, 5
• Concurrent MAOI use 5
• Within 24 hours of each other (triptans and DHE) 1, 5

Medications to Avoid

Opioids (hydrocodone, oxycodone, morphine, codeine, tramadol) and butalbital-containing compounds are absolutely contraindicated for migraine treatment because they provide questionable efficacy, carry high risk of dependence, precipitate rebound headaches, and worsen long-term outcomes. 1, 6, 3, 2

• Reserve opioids only when all other evidence-based treatments are contraindicated, sedation is acceptable, and abuse risk has been formally assessed 1
• If an opioid must be used, butorphanol nasal spray has better evidence than other opioids 1

Critical Frequency Limitation

All acute migraine medications—NSAIDs, triptans, gepants, ditans, combination analgesics—must be limited to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 6, 3, 2

• If acute treatment is needed more than twice weekly, initiate preventive therapy immediately 1, 7

Treatment Timing

Treat early when pain is still mild for maximum effectiveness: ~50% of patients become pain-free at 2 hours when treated early versus ~28% when treatment is delayed until pain is moderate-to-severe. 1

Special Populations

Pregnancy

• Acetaminophen 1000 mg is the safest option during pregnancy 6
• Sumatriptan may be considered for selected patients after risk-benefit discussion 6
• Avoid NSAIDs in third trimester 6
• Valproate is strictly contraindicated (teratogenic) 1, 7

Uncontrolled Hypertension

• Acetaminophen 1000 mg is preferred; NSAIDs can further elevate blood pressure 1
• Triptans and DHE are contraindicated 1, 5
• Gepants (ubrogepant, rimegepant) are safe alternatives 1

Cardiovascular Disease

• Gepants or ditans are preferred; triptans and DHE are contraindicated 1, 2
• NSAIDs (ketorolac) should be used with caution in heart disease 1

Drug Allergies

• If NSAID allergy: use acetaminophen 1000 mg or triptan monotherapy 1
• If triptan contraindication: use NSAID + antiemetic or gepant 1

When Initial Treatment Fails

If one triptan fails after 2–3 headache episodes, switch to a different triptan (failure of one does not predict failure of others); if all triptans fail, escalate to gepants or ditans. 1, 3, 8

• Try each triptan for 2–3 separate attacks before abandoning it 1, 5, 3
• Consider route change (e.g., subcutaneous or intranasal) if oral fails 1, 8
• Add an NSAID to the triptan rather than increasing triptan frequency 1, 5

Preventive Therapy Indications

Initiate preventive therapy when:

• ≥2 migraine attacks per month causing disability ≥3 days 1, 7
• Acute medication use exceeds 2 days per week 1, 7
• Contraindication to or failure of acute treatments 1, 7
• Patient preference for prevention 7

First-line preventive agents include propranolol 80–240 mg/day, topiramate 50–100 mg/day, or candesartan 7