This article provides a systematic, evidence-based approach to acute medication choices for the patient with migraine.
Recent clinical trials, meta-analyses, and practice guidelines have confirmed that four nonsteroidal anti-inflammatory drugs (NSAIDs) with randomized controlled trial evidence for efficacy in migraine (ibuprofen, naproxen sodium, diclofenac potassium, and acetylsalicylic acid) and seven triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, and naratriptan) are appropriate medications for acute migraine treatment. Dihydroergotamine (DHE) is also suitable for selected patients.
NSAIDs and triptans are the mainstays of acute migraine therapy, and antiemetic drugs can be added as necessary. Opioids and combination analgesics containing opioids should not be used routinely. Patient-specific clinical features should help guide the selection of an acute medication for an individual patient. Acute medications can be organized into four treatment strategies for use in various clinical settings. The acetaminophen-NSAID strategy is suitable for patients with attacks of mild to moderate severity. The triptan strategy is suitable for patients with severe attacks and for those with attacks of moderate severity who do not respond well to NSAIDs. The refractory migraine strategies may be useful for patients who do not respond well to the NSAIDs or triptans alone and include using triptans and NSAIDs simultaneously in combination, DHE, and rescue medications (eg, dopamine antagonists, combination analgesics, and corticosteroids) when the patient’s usual medications fail. Strategies for patients with contraindications to vasoconstricting drugs include use of NSAIDs, combination analgesics, and dopamine antagonists.
Acetaminophen is the safest acute migraine drug during pregnancy, and acetaminophen with codeine is also an option. Sumatriptan may be an option during pregnancy for selected patients and is compatible with breast-feeding.
Address correspondence to Dr Werner J. Becker, Foothills Hospital, Division of Neurology, 12th Floor, 1403 29th Street NW, Calgary, AB, T2N 2T9, Canada, firstname.lastname@example.org.
Relationship Disclosure: Dr Becker has served on the medical advisory boards of Allergan, Inc; Amgen Inc; electroCore Medical LLC; and Tribute Pharmaceuticals Canada, Inc, and the clinical trial steering committee of St. Jude Medical, Inc. He has received personal compensation for speaking engagements from Allergan, Inc; EMD Serono, Inc; Teva Pharmaceutical Industries Ltd; and Tribute Pharmaceuticals Canada, Inc, and for the development of educational materials for Allergan, Inc.
Unlabeled Use of Products/Investigational Use Disclosure: Dr Becker discusses the unlabeled/investigational use of butalbital, codeine, dexamethasone, dexketoprofen, dimenhydrinate, domperidone, ketorolac, metoclopramide, morphine, oxycodone, prednisone, prochlorperazine, and tramadol for the acute treatment of migraine.