Migraine (acute treatment)

Use at a glance

• Treat early in the attack

Practical pearls

• NSAID/acetaminophen for mild–moderate pain
• Triptan for moderate–severe or NSAID failure

Safety / pitfalls

• Gepant if triptan fails/is contraindicated
• Add antiemetic when nausea is prominent

Treatment pitfalls

• Lasmiditan avoids vasoconstriction but sedates
• Avoid opioids + medication overuse

Key points

• Mild–moderate pain: acetaminophen or NSAID usually suffices
• Avoid butalbital- and opioid-containing products
• Moderate–severe, no vascular disease: triptan + nonopioid analgesic
• Oral sumatriptan, almotriptan, eletriptan, rizatriptan, zolmitriptan: comparable efficacy, onset, duration
• Intranasal/injectable triptans faster; SC sumatriptan most effective, most adverse effects
• CGRP antagonists: less effective than triptans; OK with vascular disease; no MOH
• Triptan failure → ergotamine derivatives

Pearls

• Naratriptan, frovatriptan: gentler but slower, weaker initial relief
• Nasal zavegepant acts fastest among gepants
• Parenteral prochlorperazine or metoclopramide relieves pain, not just nausea
• Add diphenhydramine to curb dopamine-antagonist EPS
• After medication overuse, limit acute treatment to 2 days/week

Self-check

• When should an acute migraine attack be treated?
  Early in the attack.
• When is an antiemetic added for migraine?
  Nausea is prominent.

Drugs used for this (27)

All clinical uses · Open Migraine (acute treatment) in the interactive console ↗