Acute Migraine Headache: Treatment Strategies

Migraine is a primary headache disorder characterized by recurrent disabling attacks. Pharmacologic treatment of acute migraine episodes should be individualized based on route of administration, cost, contraindications, and adverse effects. Stratifying treatment based on migraine severity may result in more rapid resolution of symptoms and return of function. Simple analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs, are first-line treatments for mild to moderate migraine episodes, and triptans are first-line therapy for moderate to severe attacks. Antiemetics and ergot alkaloids are recommended as second-line agents and in cases of refractory migraine. Gepants and ditans are promising newer agents that are supported by quality evidence for second-line use. Unlike triptans and ergot alkaloids, gepants and ditans do not have vascular contraindications. The use of these medications is largely limited by cost, although the adverse effects of ditans also may limit their use. Opioids and butalbital-containing medications are not recommended for the treatment of migraine unless other options have been ineffective. There is insufficient evidence to recommend nonpharmacologic therapies, such as neuromodulatory devices, acupuncture, and greater occipital nerve blocks, but these therapies may be appropriate for select patients.