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.
Migraine is a complex and often disabling disease characterized by episodic attacks that impact activity and productivity.1,2 Approximately 15% of people in the United States have had a migraine, with a higher prevalence in women (20.7%) than in men (9.7%).3 In 2016, the economic burden of migraine was estimated to be more than $36 billion.2,4 Migraines account for approximately 3.6 million primary care visits annually and are the fifth most common reason for emergency department visits.4
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Initial treatment should be stratified based on migraine severity; validated screening questionnaires should be used to determine the need for escalation of therapy.15,17,18 | B | Expert opinion and limited RCTs that showed improvement in pain and symptoms |
| Nonsteroidal anti-inflammatory drugs are first-line treatment for mild to moderate migraine.12,15,21,22 | A | Consistent evidence from RCTs that showed freedom from pain and reduction in symptoms at 2 hours |
| Triptans are first-line treatment for moderate to severe migraine.12,15,21,22 | A | Consistent evidence from RCTs that showed freedom from pain and reduction in symptoms at 2 hours |
| A trial of a different triptan medication should be considered for patients who have not responded to initial triptan therapy.12,15,22 | C | Expert opinion and inconsistent RCT results |
| Use of gepants or ditans should be considered in nonpregnant adults who have not responded to treatment with more than one oral triptan medication or those in whom triptans are contraindicated or not tolerated.15,21,29,32–35,37 | A | Consistent evidence from RCTs that showed freedom from pain and most bothersome migraine symptoms at 2 hours |
| Opioids or butalbital-containing medications should be avoided for the treatment of migraine, except in refractory cases.12,15,21,39 | C | Consensus guidelines and the Choosing Wisely campaign |
RCT = randomized controlled trial.
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 https://www.aafp.org/afpsort.
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