Practice Guidelines

Guidelines on Migraine: Part 3. Recommendations for Individual Drugs



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Am Fam Physician. 2000 Nov 1;62(9):2145-2151.

The U.S. Headache Consortium guidelines on the pharmacologic management of acute migraine include recommendations for individual drugs. The recommendations are based on scientific evidence and on clinical opinion. Because few clinical trials have head-to-head comparisons of different agents, the consortium could not develop recommendations that specify the use of one agent over another. Similarly, the lack of sufficient data did not allow construction of an algorithmic approach to the selection of drug therapy for acute migraine. The second part of the migraine guidelines, published in the October 15, 2000 issue of American Family Physician, contained a table that grouped the various drugs used in the treatment of acute migraine according to the strength of the evidence for clinical benefit. In this issue, the specific recommendations for individual drugs are described. The guidelines are available at the American Academy of Neurology Web site (http://www.neurology.org) and at the American Academy of Family Physicians Web site (http://www.aafp.org).

The headache consortium evaluated data from many clinical studies and developed efficacy and safety profiles of each drug. Three categories (Grade A, Grade B and Grade C) were used to measure the quality of the evidence for clinical efficacy of the different drugs and doses. In addition, consortium participants rated the efficacy and adverse effects on the basis of the results of randomized controlled trials and on consensus of the U.S. Headache Consortium. The accompanying table summarizes findings on efficacy and safety of the various drugs used in the treatment of acute migraine.

Specific Recommendations for Individual Drugs

The following is an excerpt of the section in the migraine guidelines that outlines the findings from clinical studies and the specific recommendations for individual drugs. Definitions for the three classes of recommendations (Grades A, B and C) are at the bottom of the table on page 2146.

Summary of the Evidence for Efficacy of Drugs Used in the Treatment of Acute Migraine

Drug (doses tested) Quality of evidence* Scientific effect† Clinical impression of effect‡ Adverse effects Role (by consensus of consortium)

Antiemetics

Chlorpromazine, IM (0.1 mg per kg for 1 to 3 doses, to 1 mg per kg)

C

++

++

Mild to moderate

Adjunct therapy

Chlorpromazine, IV (12.5 to 37.5 mg)

B

++

++

Mild to moderate

Adjunct therapy

Metoclopramide, IM (10 mg)

B

+

+

Infrequent to occasional

Adjunct therapy

Metoclopramide, rectally (20 mg)

B

++

Unknown

Infrequent to occasional

Adjunct therapy

Metoclopramide, IV (0.1 mg per kg for 1 to 3 doses, to 10 mg)

B

++

++

Infrequent to occasional

Adjunct therapy

Prochlorperazine, rectally (25 mg)

B

+++

+

Occasional

Adjunct therapy

Prochlorperazine, IM (10 mg)

B

+++

++

Occasional

Adjunct first-line therapy in emergency department or office

Prochlorperazine, IV (10 mg)

B

+++

+++

Frequent

Adjunct first-line therapy in emergency department or office

Barbiturate hypnotics

Butalbital plus aspirin plus caffeine

C

Unknown

+++

Occasional

Occasional use for moderate to severe migraine; limit use due to increased risk of headache rebound and medication overuse.

Butalbital plus aspirin plus caffeine plus codeine (50 mg plus 325 mg plus 40 mg plus 30 mg)

B

++

+++

Occasional

Same as above

Ergot alkaloids and derivatives

Dihydroergotamine, SC (1 mg; dose approved: 1 mg)

B

+++

+++

Occasional

Moderate to severe migraine

Dihydroergotamine, IM (1 mg)

B

++

+++

Occasional

Moderate to severe migraine

Dihydroergotamine, IV (1 to 2 mg)

B

++

+++

Frequent

Moderate to severe migraine

Dihydroergotamine, IV plus antiemetics (0.5 to 1 mg dihydroergotamine)

B

+++

+++

Frequent

Useful in longstanding headache; may be used as therapy of choice in emergency department

Dihydroergotamine nasal spray (0.5 to 4 mg; dose approved: 2 mg)

A

++

+++

Occasional

Moderate to severe migraine; treatment option for patients with nausea and/or vomiting

Ergotamine (1 to 5 mg; dose approved 2 mg); ergotamine plus caffeine (2 to 6 mg plus 200 to 600 mg; dose approved: 2 mg ergotamine plus 200 mg caffeine); ergostine plus caffeine (2 mg plus 200 mg)

B

+

++

Frequent

Consider for select patients with moderate to severe migraine.

NSAIDs, combination analgesics and nonopiate analgesics

Acetaminophen (650 to 4,000 mg)

B

0

+

Infrequent

May be considered for use in children or pregnant patients

Ketorolac, IM (30 to 60 mg)

B

+

++

Infrequent

Consider for use in emergency department.

Aspirin, orally (500 to 1,000 mg)

A

++

++

Occasional

First-line agent

Diclofenac K, orally (50 to 100 mg)

B

++

++

Occasional

First-line agent

Flurbiprofen, orally (100 to 300 mg)

B

+

++

Occasional

First-line agent

Ibuprofen, orally (400 to 2,400 mg)

A

++

++

Occasional

First-line agent

Naproxen, orally (750 to 1,250 mg)

B

+

++

Occasional

First-line agent

Naproxen sodium, orally (750 to 1,750 mg)

A

++

++

Occasional

First-line agent

Piroxicam, SL (40 mg)

B

+

++

Occasional

First-line agent

NSAIDs, combination analgesics and nonopiate analgesics (continued)

Acetaminophen plus aspirin plus caffeine (500 mg plus 500 mg plus 130 mg; dose approved: 500 mg plus 500 mg plus 130 mg [2 tablets])

A

+++

++

Infrequent

First-line agent

Opiate analgesics

Butorphanol nasal spray (1 to 2 mg; dose approved: 1 mg)

A

+++

+++

Frequent

Moderate to severe migraine; use as rescue therapy; limit use due to risk of rebound and medication overuse

Acetaminophen plus codeine, orally (400 to 650 mg plus 16 to 25 mg)

A

++

++

Occasional

Moderate to severe migraine; limit use due to increased risk of headache rebound and dependency

Butorphanol, IM (1 to 3 mg); meperidine, IM (75 to 100 mg); meperidine, IV (0.4 mg per kg, up to 3 doses); methadone (10 mg)

B

++

++

Frequent

Reserved for emergency department use or as rescue medication; limit use due to increased risk of headache rebound and dependency

Serotonin receptor agonists (triptans)

Sumatriptan nasal spray (1 to 40 mg; dose approved: 5, 10 and 20 mg)

A

+++

+++

Occasional

Moderate to severe migraine; especially useful when nonoral administration is needed

Naratriptan, orally (1 to 2.5 mg; dose approved: 1 and 2.5 mg)

A

++

++

Infrequent

Moderate to severe migraine

Rizatriptan, orally (5 to 40 mg; dose approved: 5 and 10 mg)

A

+++

+++

Occasional

Moderate to severe migraine

Sumatriptan, orally (25 to 100 mg; dose approved: 25 and 50 mg)

A

+++

+++

Occasional

Moderate to severe migraine

Zolmitriptan, orally (1 to 25 mg; dose approved: 2.5 mg and 5 mg)

A

+++

+++

Occasional

Moderate to severe migraine

Sumatriptan, SC (1 to 8 mg; dose approved: 6 mg)

A

+++

+++

Frequent

Moderate to severe migraine; especially useful when nonoral administration is needed

Other medications

Corticosteroids, IV, plus antiemetics; dexamethasone (6 mg); hydrocortisone (50 mg)

C

+

++

Infrequent

Rescue therapy in status migrainosus

Isometheptene (130 to 780 mg); Midrid (2 to 6 capsules); Midrin (2 to 5 capsules)

B

+

++

Infrequent

Consider for patients with mild to moderate headache.

Lidocaine, IN (4 percent solution, 1 to 4 drops)

B

++

Unknown

Frequent

Uncertain


IM = intramuscularly; IN = intranasally; IV = intravenously; SC = subcutaneously; SL = sublingually.

*—Quality of the evidence is classified as follows: Grade A signifies evidence from multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent pattern of findings. Grade B signifies some evidence from randomized clinical trials supported the recommendation, but the scientific support was not optimal. For instance, few randomized trials existed, the trials that did exist were somewhat inconsistent or the trials were not directly relevant to the recommendation. An example of the last point would be the case where trials were conducted using a study group that differed from the target group for the recommendation. Grade C signifies that the U.S. Headache Consortium achieved consensus on the recommendation in the absence of relevant randomized controlled trials.

†—Scientific effect is classified as follows: 0 = the drug is ineffective or harmful; + = the effect is not statistically or not clinically significant (i.e., less than the minimal clinically significant benefit); ++ = the effect is statistically significant and exceeds the minimal clinically significant benefit; +++ = the effect is statistically significant and far exceeds the minimal clinically significant benefit.

‡—Clinical impression of effect is classified as follows: 0 = most patients do not get relief; + = few people get complete relief; some people get some relief; ++ = some people get complete relief; most get some relief; +++ = most people get complete or nearly complete relief.

Reprinted with permission from Matchar DB, Young WB, Rosenberg JH, Pietrzak MP, Silberstein SD, Lipton RB, et al. U.S. Headache Consortium. Evidence-based guidelines for migraine headache in the primary care setting: pharmacological management of acute attacks. Copyright by the American Academy of Neurology.

Summary of the Evidence for Efficacy of Drugs Used in the Treatment of Acute Migraine

View Table

Summary of the Evidence for Efficacy of Drugs Used in the Treatment of Acute Migraine

Drug (doses tested) Quality of evidence* Scientific effect† Clinical impression of effect‡ Adverse effects Role (by consensus of consortium)

Antiemetics

Chlorpromazine, IM (0.1 mg per kg for 1 to 3 doses, to 1 mg per kg)

C

++

++

Mild to moderate

Adjunct therapy

Chlorpromazine, IV (12.5 to 37.5 mg)

B

++

++

Mild to moderate

Adjunct therapy

Metoclopramide, IM (10 mg)

B

+

+

Infrequent to occasional

Adjunct therapy

Metoclopramide, rectally (20 mg)

B

++

Unknown

Infrequent to occasional

Adjunct therapy

Metoclopramide, IV (0.1 mg per kg for 1 to 3 doses, to 10 mg)

B

++

++

Infrequent to occasional

Adjunct therapy

Prochlorperazine, rectally (25 mg)

B

+++

+

Occasional

Adjunct therapy

Prochlorperazine, IM (10 mg)

B

+++

++

Occasional

Adjunct first-line therapy in emergency department or office

Prochlorperazine, IV (10 mg)

B

+++

+++

Frequent

Adjunct first-line therapy in emergency department or office

Barbiturate hypnotics

Butalbital plus aspirin plus caffeine

C

Unknown

+++

Occasional

Occasional use for moderate to severe migraine; limit use due to increased risk of headache rebound and medication overuse.

Butalbital plus aspirin plus caffeine plus codeine (50 mg plus 325 mg plus 40 mg plus 30 mg)

B

++

+++

Occasional

Same as above

Ergot alkaloids and derivatives

Dihydroergotamine, SC (1 mg; dose approved: 1 mg)

B

+++

+++

Occasional

Moderate to severe migraine

Dihydroergotamine, IM (1 mg)

B

++

+++

Occasional

Moderate to severe migraine

Dihydroergotamine, IV (1 to 2 mg)

B

++

+++

Frequent

Moderate to severe migraine

Dihydroergotamine, IV plus antiemetics (0.5 to 1 mg dihydroergotamine)

B

+++

+++

Frequent

Useful in longstanding headache; may be used as therapy of choice in emergency department

Dihydroergotamine nasal spray (0.5 to 4 mg; dose approved: 2 mg)

A

++

+++

Occasional

Moderate to severe migraine; treatment option for patients with nausea and/or vomiting

Ergotamine (1 to 5 mg; dose approved 2 mg); ergotamine plus caffeine (2 to 6 mg plus 200 to 600 mg; dose approved: 2 mg ergotamine plus 200 mg caffeine); ergostine plus caffeine (2 mg plus 200 mg)

B

+

++

Frequent

Consider for select patients with moderate to severe migraine.

NSAIDs, combination analgesics and nonopiate analgesics

Acetaminophen (650 to 4,000 mg)

B

0

+

Infrequent

May be considered for use in children or pregnant patients

Ketorolac, IM (30 to 60 mg)

B

+

++

Infrequent

Consider for use in emergency department.

Aspirin, orally (500 to 1,000 mg)

A

++

++

Occasional

First-line agent

Diclofenac K, orally (50 to 100 mg)

B

++

++

Occasional

First-line agent

Flurbiprofen, orally (100 to 300 mg)

B

+

++

Occasional

First-line agent

Ibuprofen, orally (400 to 2,400 mg)

A

++

++

Occasional

First-line agent

Naproxen, orally (750 to 1,250 mg)

B

+

++

Occasional

First-line agent

Naproxen sodium, orally (750 to 1,750 mg)

A

++

++

Occasional

First-line agent

Piroxicam, SL (40 mg)

B

+

++

Occasional

First-line agent

NSAIDs, combination analgesics and nonopiate analgesics (continued)

Acetaminophen plus aspirin plus caffeine (500 mg plus 500 mg plus 130 mg; dose approved: 500 mg plus 500 mg plus 130 mg [2 tablets])

A

+++

++

Infrequent

First-line agent

Opiate analgesics

Butorphanol nasal spray (1 to 2 mg; dose approved: 1 mg)

A

+++

+++

Frequent

Moderate to severe migraine; use as rescue therapy; limit use due to risk of rebound and medication overuse

Acetaminophen plus codeine, orally (400 to 650 mg plus 16 to 25 mg)

A

++

++

Occasional

Moderate to severe migraine; limit use due to increased risk of headache rebound and dependency

Butorphanol, IM (1 to 3 mg); meperidine, IM (75 to 100 mg); meperidine, IV (0.4 mg per kg, up to 3 doses); methadone (10 mg)

B

++

++

Frequent

Reserved for emergency department use or as rescue medication; limit use due to increased risk of headache rebound and dependency

Serotonin receptor agonists (triptans)

Sumatriptan nasal spray (1 to 40 mg; dose approved: 5, 10 and 20 mg)

A

+++

+++

Occasional

Moderate to severe migraine; especially useful when nonoral administration is needed

Naratriptan, orally (1 to 2.5 mg; dose approved: 1 and 2.5 mg)

A

++

++

Infrequent

Moderate to severe migraine

Rizatriptan, orally (5 to 40 mg; dose approved: 5 and 10 mg)

A

+++

+++

Occasional

Moderate to severe migraine

Sumatriptan, orally (25 to 100 mg; dose approved: 25 and 50 mg)

A

+++

+++

Occasional

Moderate to severe migraine

Zolmitriptan, orally (1 to 25 mg; dose approved: 2.5 mg and 5 mg)

A

+++

+++

Occasional

Moderate to severe migraine

Sumatriptan, SC (1 to 8 mg; dose approved: 6 mg)

A

+++

+++

Frequent

Moderate to severe migraine; especially useful when nonoral administration is needed

Other medications

Corticosteroids, IV, plus antiemetics; dexamethasone (6 mg); hydrocortisone (50 mg)

C

+

++

Infrequent

Rescue therapy in status migrainosus

Isometheptene (130 to 780 mg); Midrid (2 to 6 capsules); Midrin (2 to 5 capsules)

B

+

++

Infrequent

Consider for patients with mild to moderate headache.

Lidocaine, IN (4 percent solution, 1 to 4 drops)

B

++

Unknown

Frequent

Uncertain


IM = intramuscularly; IN = intranasally; IV = intravenously; SC = subcutaneously; SL = sublingually.

*—Quality of the evidence is classified as follows: Grade A signifies evidence from multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent pattern of findings. Grade B signifies some evidence from randomized clinical trials supported the recommendation, but the scientific support was not optimal. For instance, few randomized trials existed, the trials that did exist were somewhat inconsistent or the trials were not directly relevant to the recommendation. An example of the last point would be the case where trials were conducted using a study group that differed from the target group for the recommendation. Grade C signifies that the U.S. Headache Consortium achieved consensus on the recommendation in the absence of relevant randomized controlled trials.

†—Scientific effect is classified as follows: 0 = the drug is ineffective or harmful; + = the effect is not statistically or not clinically significant (i.e., less than the minimal clinically significant benefit); ++ = the effect is statistically significant and exceeds the minimal clinically significant benefit; +++ = the effect is statistically significant and far exceeds the minimal clinically significant benefit.

‡—Clinical impression of effect is classified as follows: 0 = most patients do not get relief; + = few people get complete relief; some people get some relief; ++ = some people get complete relief; most get some relief; +++ = most people get complete or nearly complete relief.

Reprinted with permission from Matchar DB, Young WB, Rosenberg JH, Pietrzak MP, Silberstein SD, Lipton RB, et al. U.S. Headache Consortium. Evidence-based guidelines for migraine headache in the primary care setting: pharmacological management of acute attacks. Copyright by the American Academy of Neurology.

  • Oral antiemetics in generalFindings: Studies of specific agents, such as domperidone and prochlorperazine, suggest some clinical benefit, but studies are limited. No studies were identified for other oral antiemetics as monotherapy to manage acute migraine attacks.

    Recommendation: Oral antiemetics may be used as an adjunct in the treatment of nausea associated with migraine (Grade C recommendation).

  • Intramuscular (IM) metoclopramideFindings: Studies did not demonstrate efficacy as monotherapy for the treatment of acute migraine.

    Recommendation: IM metoclopramide may be considered as an adjunct to control nausea in the treatment of migraine (Grade C recommendation).

  • Intravenous (IV) metoclopramideFindings: Two out of three studies reported that IV metoclopramide is effective for the acute treatment of migraine.

    Recommendation: IV metoclopramide may be an appropriate choice as adjunct therapy for the treatment of pain or nausea in the appropriate setting (Grade C recommendation). It may be considered as monotherapy for migraine pain relief (Grade B recommendation).

  • Parenteral prochlorperazineFindings: One study each evaluated the efficacy of prochlorperazine IM, IV and rectally and found it to be relatively safe and effective for the treatment of migraine headache and associated nausea and vomiting.

    Recommendation: Prochlorperazine IM, IV and rectally may be a therapeutic choice for migraine in the appropriate setting (Grade B recommendation). Prochlorperazine rectally may be considered an adjunct in the treatment of acute migraine with nausea and vomiting (Grade C recommendation).

  • Serotonin receptor (5-HT3) antagonistsFindings: Studies of the efficacy of granisetron and zatosetron (not currently available in the United States) did not demonstrate a statistically significant clinical benefit for headache relief. Sufficient studies have not been done to demonstrate the clinical efficacy of this class of drug.

    Recommendation: Evidence is insufficient to establish or refute a role for 5-HT3 antagonists as monotherapy in the management of acute attacks (Grade B recommendation). However, 5-HT3 antagonists may be considered as adjunct therapy to control nausea in select patients with migraine attacks (Grade C recommendation).

  • Butalbital-containing agentsFindings: No randomized, placebo-controlled studies prove or refute efficacy of butalbital-containing agents in the treatment of acute migraine headaches.

    Recommendation: Based on concerns of overuse, medication-overuse headache and withdrawal, the use of butalbital-containing analgesics should be limited and carefully monitored (Grade B recommendation).

  • Oral and rectal ergotamine (and caffeine combination)Findings: Evidence is inconsistent to support efficacy of ergotamine for the treatment of migraine. Studies documented a higher incidence of adverse events with ergots as compared with placebo, sumatriptan, isometheptene, nonsteroidal anti-inflammatory drugs (NSAIDs) or dextropropoxyphene compounds.

    Recommendation: In the treatment of select patients with moderate to severe migraine, ergot derivatives may be considered (Grade B recommendation).

  • Subcutaneous (SC), IV and IM dihydroergotamine (DHE)Findings: No placebo-controlled trials in migraine patients have demonstrated efficacy and safety as monotherapy. Clinical opinion suggests that SC DHE is relatively safe and effective when compared with other migraine therapies and that SC DHE has fewer adverse events than IV DHE.

    Recommendation: Because of their inability to tolerate or take oral medication, patients with nausea and vomiting may be given SC, IV or IM DHE (Grade C recommendation). Initial treatment with SC or IM DHE is a reasonable choice when the headache is moderate to severe or when an adequate trial of NSAIDs or other nonopiate analgesics, including combination analgesics such as acetaminophen plus aspirin plus caffeine, has failed to provide adequate relief in the past (Grade C recommendation). The use of IM or SC DHE may be considered in patients with moderate to severe migraine (Grade B recommendation).

  • IV DHE plus IV antiemeticFindings: The combination of IV DHE and antiemetic has been shown to be effective and moderately safe in the treatment of moderate to severe migraine as compared with parenteral opiates.

    Recommendation: IV DHE plus antiemetics is an appropriate treatment choice for patients with severe migraine (Grade B recommendation).

  • DHE nasal sprayFindings: DHE nasal spray is safe and effective for the treatment of acute migraine attacks.

    Recommendation: DHE nasal spray is an appropriate treatment choice and should be considered for use in patients with moderate to severe migraine (Grade A recommendation). Because of their inability to tolerate or take oral medications, patients with nausea and vomiting may be given intranasal DHE (Grade C recommendation). Initial treatment with DHE nasal spray is a reasonable choice when the headache is moderate to severe or when an adequate trial of NSAIDs or other nonopiate analgesics, including combination analgesics such as acetaminophen plus aspirin plus caffeine, has failed to provide adequate relief in the past (Grade C recommendation).

  • AcetaminophenFindings: No evidence establishes the efficacy of acetaminophen in the acute treatment of migraine.

    Recommendation: Acetaminophen is not a specific treatment option for migraine (Grade B recommendation).

  • Oral NSAIDs and combination analgesics in generalFindings: The most consistent evidence exists for aspirin, ibuprofen, naproxen sodium, tolfenamic acid (not currently available in the United States) and the combination agent acetaminophen plus aspirin plus caffeine. Limited (only one study) or inconsistent (some positive and some negative) evidence exists for other NSAIDs.

    Recommendation: Their favorable tolerability makes these agents a reasonable first-line treatment choice for mild to moderate migraine attacks or severe attacks that have been responsive in the past to similar NSAIDs or nonopiate analgesics (Grade A recommendation).

  • IM ketorolacFindings: No placebo-controlled trials testing the efficacy of IM ketorolac for the treatment of acute migraine attack have been published. Small comparative trials suggest possible equivalence to some agents, and a single comparison trial with meperidine demonstrated inferiority.

    Recommendation: IM ketorolac is an option that may be used in a physician-supervised setting, although conclusions regarding clinical efficacy cannot be made at this time (Grade C recommendation).

  • Butorphanol nasal sprayFindings: The clinical efficacy of butorphanol specifically for migraine has been documented in two published reports.

    Recommendation: Clinical experience and expert consensus concur that butorphanol represents a treatment option for some patients with migraine (Grade A recommendation). Specifically, butorphanol may be considered when other medications cannot be used or as a rescue medication when significant sedation would not jeopardize the patient (Grade C recommendation). Clinical concerns regarding the use of butorphanol lie in the fact that it is widely used despite the established risk of overuse and dependence. In certain patients for whom use might be indicated, special attention should be given to these clinical concerns.

  • Oral combination opiatesFindings: Studies demonstrate the effectiveness of oral opiate combination agents in terms of pain relief.

    Recommendation: Oral opiate combinations may be considered for use in acute migraine when sedation side effects will not put the patient at risk and/or the risk for abuse has been addressed (Grade A recommendation).

  • IM and IV opiatesFindings: Only one placebo-controlled study has been published for IM methadone and IM meperidine. This study demonstrated the effectiveness of opiates for pain relief.

    Recommendation: Parenteral opiates may be considered for rescue therapy in a supervised setting when sedation side effects will not put the patient at risk and when the risk of abuse has been addressed (Grade B recommendation).

  • Serotonin receptor agonists, or “triptans”—Findings: These agents (naratriptan, rizatriptan, sumatriptan and zolmitriptan) are effective and relatively safe for the acute treatment of migraine headaches. No evidence supports their use during the aura phase of an attack. (Published case reports of cardiovascular ischemic events with this class of drug are found in the literature and are included in the product label.)

    Recommendation: The triptans are an appropriate treatment choice and may be considered for use in patients with moderate to severe migraine who have no contraindications to their use (Grade A recommendation). Because of their inability to take oral medications, patients with nausea and vomiting may be given intranasal or SC sumatriptan (Grade C recommendation). Migraine-specific agents (triptans, DHE, ergotamine) should be used in patients with more severe migraine and in those whose headaches respond poorly to NSAIDs or combination analgesics such as aspirin plus acetaminophen plus caffeine (Grade C recommendation).

  • Isometheptene and isometheptene-combination agentsFindings: Isometheptene-containing compounds are superior to placebo, with a small but statistically significant effect.

    Recommendation: Based on clinical evidence and favorable tolerability, isometheptene-containing compounds may be a reasonable choice for patients with mild to moderate headache (Grade B recommendation).

  • Dexamethasone or hydrocortisoneFindings: No studies of good quality support or refute the effectiveness of steroids for acute migraine.

    Recommendation: Corticosteroids may be considered as a treatment choice for rescue therapy in patients with status migrainosus (Grade C recommendation).

  • Intranasal and IV lidocaineFindings: Limited studies of intranasal lidocaine reported lidocaine to be superior to placebo in relieving acute migraine headache at 15 minutes. Mixed results have been reported in the incidence of recurrence. A few small studies suggest that IV lidocaine is not significantly better than placebo and is less effective than other parenteral therapies for the treatment of acute migraine.

    Recommendation: Evidence is insufficient at this time to establish a defined role for intranasal lidocaine in the management of acute migraine (Grade B recommendation). Evidence is insufficient to support the role of IV lidocaine in the management of acute migraine (Grade B recommendation).


This is the third of a five-part series summarizing the U.S. Headache Consortium guidelines on migraine. The first part, on the use of diagnostic imaging in nonacute headache, appeared in the October 1 issue of American Family Physician. The second part, on the general principles of drug therapy, appeared in the October 15 issue. The fourth part, on prevention of migraine, will appear in the next issue.

Funding and support for the evidence-based migraine guidelines were provided by Abbott Laboratories, AstraZeneca, Bristol Myers Squibb, Glaxo Wellcome, Merck, Pfizer, Ortho-McNeil and the American Academy of Neurology Education and Research Foundation, along with the seven participant member organizations, which include the American Academy of Family Physicians, the American Academy of Neurology, the American Headache Society, the American College of Emergency Physicians, the American College of Physicians-American Society of Internal Medicine, the American Osteopathic Association and the National Headache Foundation.


Copyright © 2000 by the American Academy of Family Physicians.
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