From the Guidelines
For acute episodic migraine headache, consider treating with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen as first-line treatment. This approach is based on the most recent clinical guideline from the American College of Physicians, published in the Annals of Internal Medicine in 2025 1. The guideline suggests that if patients do not achieve sufficient pain relief with an NSAID or acetaminophen, consider increasing the dosage without exceeding the recommended maximum daily dose.
Some key points to consider when treating headache include:
- Using the appropriate dosage of medication and considering individual patient preferences, such as route of administration and cost 1.
- Avoiding the use of opioids or butalbital for the treatment of acute episodic migraine, as they are not recommended due to potential adverse effects and lack of efficacy 1.
- Considering the use of 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.
- Counseling patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy to improve efficacy, and being aware of medication overuse headache as a potential complication of migraine treatment 1.
It is essential to individualize treatment decisions, taking into account patient-specific factors and preferences, to optimize outcomes and minimize adverse effects. Always prioritize the use of evidence-based treatments and avoid medications with potential harm, such as opioids, to ensure the best possible outcomes for patients with headache.
From the FDA Drug Label
Ergotamine Tartrate and Caffeine Indicated as therapy to abort or prevent vascular headache, e.g., migraine, migraine variants or so-called “histaminic cephalalgia”. Ergomar® is indicated as therapy to abort or prevent vascular headache, e.g., migraine, migraine variants or so-called "histaminic cephalalgia".
Medications for headache include:
These medications are indicated for the treatment of migraine and other vascular headaches.
From the Research
Medications for Headache
- The primary goals of acute migraine therapy are to reduce attack duration and severity, and current evidence-based therapies for acute migraine attacks include:
- Over-the-counter medications, such as acetaminophen, ibuprofen, naproxen, and aspirin, are considered a first-line therapy for most migraineurs due to their efficacy, lower cost, and fewer adverse effects 5
- The administration of acute medications should follow the concept of "stratified care", with oral NSAIDs as the first choice for mild to moderate migraine attacks, and oral or nasal spray triptans and ergotamine/caffeine compounds recommended for moderate to severe attacks 6
- Acetaminophen is suitable for mild to moderate migraine attacks and remains the first choice for children and pregnant women 6, 8
- Preventive treatments, such as antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, can reduce migraine frequency by 1 to 3 days per month relative to placebo 8
- Newer treatments, such as gepants and lasmiditan, have shown efficacy in acute migraine treatment, but may have adverse effects such as nausea and dry mouth 8, 9
- Nonpharmacologic treatments, such as remote electrical neuromodulation, transcranial magnetic stimulation, external trigeminal nerve stimulation, and noninvasive vagus nerve stimulation, have also shown promise in improving pain and function 9