Acute Migraine Treatment Options

Acute treatment is initiated at the start of an attack to relieve pain and stop progression. Acute therapy is restricted to a maximum of 2 to 3 days per week - because more frequent use of acute medications can actually lead to more frequent headaches called 'rebound' or 'medication overuse' headaches.

The most common medications to stop migraines once they stop are in the category if 'triptans'. There are several on the market. Sumatriptan 25 mg within 30 minutes of onset of headache is the most commonly prescribed triptan medication. It can only be taken 9 times a month because it raises blood pressure as well. The medication normally kicks in within 15 minutes to 1 hour and MUST be taken at first onset of the headache to work. Other common over the counters are normally a mix of caffeine and NSAIDs. Nausea meducations have also been shown to stop migraines after they start.

First line recommendation from the AHS is a triptan. Sumatriptan has been around the longest, overall response rate is around 30-40%, and is normally the least expensive. Zolmitriptan (Zomig) has a longer half-life than and a more rapid Tmax. Rizatriptan (Maxalt) has a more rapid Tmax . Eletriptan (Relpax) showed a small improvement when compared to sumatriptan at 2 hours, in one study. Almotriptan (Axert®) has a good adverse event profile. Frovatriptan (Frova) has lower side effects but also may have lower efficacy. Naratriptan (Amerge) has longer half-life and lower recurrence rate within 24 hours, but some reports also indicate lower efficacy.

The following have recieved Level A support for acute migraine treatment from the AHS:

Analgesics: Acetaminophen 1000 mg (for nonincapacitating attacks)

Ergots: DHE nasal spray 2 mg and pulmonary inhaler 1 mg

NSAIDs: Aspirin 500 mg, Diclofenac 50, 100 mg, Ibuprofen 200, 400 mg, Naproxen 500, 550 mg

Opioids: Butorphanol nasal spray 1 mg

Triptans: Almotriptan 12.5 mg, Eletriptan 20, 40, 80 mg, Frovatriptan 2.5 mg, Naratriptan 1, 2.5 mg, Rizatriptan 5, 10 mg, Sumatriptan oral 25, 50, 100 mg; nasal spray 10, 20 mg; patch 6.5 mg; subcutaneous injection 4, 6 mg, Zolmitriptan nasal spray 2.5, 5 mg; oral 2.5, 5 mg

Combinations: Acetaminophen/aspirin/caffeine 500/500/130 mg, Sumatriptan/naproxen 85/500 mg