Acute Migraine Headache: Treatment Strategies

Key points

• Acetaminophen and NSAIDs are first-line treatments for mild to moderate migraine; triptans are first-line for moderate to severe migraine.
• Medication should be taken early in the attack, and a stratified approach based on attack severity helps make treatment cost-effective.
• Acute medications, including triptans, should not be used more than two or three times per week; if needed more often, prophylactic therapy should be considered.
• Dopamine antagonist antiemetics are second-line; parenteral dihydroergotamine, magnesium sulfate, valproate and opioids are reserved for refractory migraine.
• Acetaminophen and metoclopramide are the only migraine treatments considered safe in pregnancy.

Overview

This American Family Physician review covers the pharmacologic treatment of acute migraine. Migraine is a primary headache disorder with recurrent attacks; according to 2009 data, about 44.5 million U.S. adults (18% to 26% of women and 6% to 9% of men) have experienced a migraine. Treatment can be individualized because the available drugs differ widely in pharmacology, adverse effects, cost and route of administration.

Diagnosis

Diagnosis relies on International Headache Society criteria and the POUND mnemonic (pulsatile, one-day duration, unilateral, nausea or vomiting, disabling intensity). Testing is indicated only to identify secondary headaches or comorbid conditions. Red flags requiring neuroimaging and/or urgent referral include a thunderclap headache, a change in the established pattern or the worst headache ever, neurologic signs or seizures, new onset after 50 years of age, progressively increasing severity and symptoms of systemic disorders.

Strategies and first-line drugs

In a comparative trial, the stratified approach relieved pain at two hours more often than step care but caused more adverse effects. The recommended acetaminophen dose is 1,000 mg; aspirin is effective at 1,000 mg but has the greatest risk of gastric irritation. For ibuprofen, the number needed to treat (NNT) at two hours is 3 for improving pain to mild and 7 for complete relief; naproxen is typically 500 mg. Acetaminophen/aspirin/caffeine also has strong evidence. Standard-dose triptans gave headache relief at two hours in 42% to 76% of patients and complete relief in 18% to 50%; subcutaneous sumatriptan 6 mg has the most favorable NNT for complete relief (2). In migraine with aura, taking the triptan at the onset of pain gives the best results. Sumatriptan 50 mg plus naproxen 500 mg was noninferior to the fixed-dose combination pill.

Second-line and refractory treatment

Intranasal dihydroergotamine is effective but has more adverse effects than triptans, with nausea common. Metoclopramide and prochlorperazine are the most studied antiemetics; all dopamine antagonists carry a risk of extrapyramidal effects. Ketorolac 30 to 60 mg is commonly used parenterally. Vasoconstrictors should be avoided for 24 hours after a triptan. Intravenous magnesium sulfate 1 to 2 g may help migraine with aura, evidence for intravenous valproate is contradictory, diphenhydramine is not recommended, and corticosteroids such as intravenous dexamethasone can help decrease recurrence. Opioids should be used sparingly and infrequently.

Special populations

In children, ibuprofen gave the best results among acetaminophen and NSAIDs; almotriptan (12 to 17 years), rizatriptan (6 to 17 years) and sumatriptan/naproxen (12 years and older) are FDA approved. Triptans and other vasoconstrictors are contraindicated in coronary artery disease and in hemiplegic and basilar migraine, where acetaminophen/aspirin/caffeine is most helpful.

Frequently asked questions

Which medicine should be tried first for a migraine attack?

Acetaminophen or an NSAID for mild to moderate attacks, and a triptan for moderate to severe attacks, taken early in the attack.

How often can acute migraine medicines be used?

No more than two or three times per week; if they are needed more often, preventive therapy should be considered.

What if the migraine comes back after a triptan?

If a migraine resolves but recurs within 24 hours, the initial triptan is likely to work again; adding naproxen 500 mg or choosing a triptan with a longer half-life may reduce recurrence.

Source

Mayans L, Walling A. Acute Migraine Headache: Treatment Strategies. American Family Physician. 2018;97(4):243-251. Published by the American Academy of Family Physicians; the journal page notes that a more recent AFP article on acute migraine is available. This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.