The goals of acute treatment in migraine should be sustained pain-free response, which will reduce disability and optimally restore function with minimal adverse events and cost. A validated four-item tool, Migraine-ACT, can measure adequacy of acute treatment.
The strategy for picking the right acute treatment initially should be one of stratified care, matching patient need to migraine characteristics. Disability is a surrogate marker for disease severity, allowing for the decision as to when to use migraine-specific treatment versus nonspecific treatment in the absence of vascular disease.
The evidence for efficacy of nonspecific treatments in migraine is mixed, due to variabilities in study designs, but they can be effective for moderate level migraine with low disability. Most studies for acute treatment with oral opioids have been poorly designed or negative. No randomized controlled trials have shown benefit for butalbital mixtures in the acute treatment of migraine.
Migraine-specific treatments include triptans and ergots. Triptans are divided into groups by speed of onset and formulation. When possible, patients should be instructed to take these medications early in the migraine attack to make a sustained pain-free response more likely. Ergot use is limited by poor oral absorption and adverse events.