Acute Migraine Headache: Treatment Strategies

Laura Mayans; Anne Walling

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Feb 15, 2018 Issue

Acute Migraine Headache: Treatment Strategies

LAURA MAYANS, MD, MPH, and ANNE WALLING, MB, ChB, University of Kansas School of Medicine, Wichita, Kansas

Am Fam Physician. 2018 Feb 15;97(4):243-251.

Patient information: A handout on this topic is available at https://familydoctor.org/condition/migraines.

Author disclosure: No relevant financial affiliations.

Migraine is a primary headache disorder characterized by recurrent attacks. Acetaminophen, nonsteroidal anti-inflammatory drugs, triptans, antiemetics, ergot alkaloids, and combination analgesics have evidence supporting their effectiveness in the treatment of migraine. Acetaminophen and nonsteroidal anti-inflammatory drugs are first-line treatments for mild to moderate migraines, whereas triptans are first-line treatments for moderate to severe migraines. Although triptans are effective, they may be expensive. Other medications such as dihydroergotamine and antiemetics are recommended for use as second- or third-line therapy for select patients or for those with refractory migraine. The pharmacologic properties, potential adverse effects, cost, and routes of administration vary widely, allowing therapy to be individualized based on the pattern and severity of attacks. Several treatment principles, including taking medication early in an attack and using a stratified treatment approach, can help ensure that migraine treatment is cost-effective.

Migraine is a primary headache disorder characterized by recurrent attacks. Approximately 44.5 million U.S. adults (18% to 26% of women and 6% to 9% of men) have experienced a migraine, according to 2009 data.1 Estimated annual U.S. direct costs for migraine are more than $17 billion; the costs of lost productivity and reduced quality of life are significantly higher.2 More than one-half of migraines are treated in primary care, and they are the fourth most common cause of emergency department visits.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	References
Nonsteroidal anti-inflammatory drugs are a first-line treatment for mild to moderate migraine. The choice of medication should be based on availability and adverse effect profile.	A	8, 11, 12, 15–19
Triptans are a first-line treatment for moderate to severe migraine. Several triptans are available with different pharmacokinetics and routes of administration.	A	8, 22, 23
The choice of triptan should be individualized based on the patient's migraine characteristics and on the route of administration, pharmacokinetics, and cost.	C	8, 22, 23
Dopamine antagonist antiemetics are second-line treatments for migraine.	B	8, 29
Parenteral dihydroergotamine (DHE 45), magnesium sulfate, valproate (Depacon), and opioids should be reserved for refractory migraine because of adverse effects, weaker evidence of effectiveness, and/or abuse potential.	B	8, 31, 34–36

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	References
Nonsteroidal anti-inflammatory drugs are a first-line treatment for mild to moderate migraine. The choice of medication should be based on availability and adverse effect profile.	A	8, 11, 12, 15–19
Triptans are a first-line treatment for moderate to severe migraine. Several triptans are available with different pharmacokinetics and routes of administration.	A	8, 22, 23
The choice of triptan should be individualized based on the patient's migraine characteristics and on the route of administration, pharmacokinetics, and cost.	C	8, 22, 23
Dopamine antagonist antiemetics are second-line treatments for migraine.	B	8, 29
Parenteral dihydroergotamine (DHE 45), magnesium sulfate, valproate (Depacon), and opioids should be reserved for refractory migraine because of adverse effects, weaker evidence of effectiveness, and/or abuse potential.	B	8, 31, 34–36

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BEST PRACTICES IN NEUROLOGY

Recommendations from the Choosing Wisely Campaign

Recommendation	Sponsoring organization
Do not use opioids or butalbital for migraine except as a last resort.	American Academy of Neurology
Do not prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders.	American Headache Society
Do not recommend prolonged or frequent use of over-the-counter pain medications for headache.	American Headache Society

Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN NEUROLOGY

The Authors

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LAURA MAYANS, MD, MPH, is an assistant professor in the Department of Family and Community Medicine at University of Kansas School of Medicine, Wichita....

ANNE WALLING, MB, ChB, is a professor in the Department of Family and Community Medicine at University of Kansas School of Medicine.

Address correspondence to Laura Mayans, MD, MPH, University of Kansas School of Medicine, 1010 N. Kansas St., Wichita, KS 67214 (e-mail: lmayans@kumc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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