KEY POINTS FOR PRACTICE
• Abortive medications are most effective when taken early in the headache phase. Most medications, including triptans and NSAIDs, are not effective when taken during migraine aura.
• Triptans are more effective than acetaminophen and NSAIDs, but there is limited additional benefit in increasing triptan dose.
• Although menstrual migraines respond less to medications, triptans (with or without NSAIDs) are effective.
• In children, acetaminophen and ibuprofen are more effective than placebo, whereas triptans are not consistently superior.
From the AFP Editors
Migraine headaches are common throughout the world. The International Headache Society (IHS) published guidelines for acute migraine medical treatment.
MEDICATION TIMING
Abortive medications should be taken early in the headache phase while headache intensity is mild. Most medications, including triptans and nonsteroidal anti-inflammatory drugs (NSAIDs), are not effective in the prodrome or aura phase. However, ubrogepant (Ubrelvy) appears to be effective when taken before the headache phase.
When patients experience early vomiting with migraines, nonoral formulations such as subcutaneous injections, intranasal sprays, and suppositories should be considered. Oral disintegrating tablets can also be trialed. Combining antiemetics with triptans or NSAIDs can improve nausea and vomiting, and triptans appear to be more effective than the combination of an NSAID and antiemetic medication.
To prevent medication overuse headache, the IHS recommends limiting the use of analgesics and NSAIDs to 3 days per week and 10 days per month. For triptans and combined analgesics, the recommendation is to limit use to 2 days per week and 8 days per month.
MEDICATIONS
Analgesics
Analgesic medications, including acetaminophen and NSAIDs, are widely available and can be beneficial for migraine when taken early in the headache course.
Triptans
The triptan class of medications is a more specific treatment for migraines and are more effective than analgesics. However, triptans tend to be less effective in menstrual migraines and those with onset during sleep.
Comparative studies consistently demonstrate that triptans more effectively lead to headache resolution in 2 hours. In one study, 10 mg of rizatriptan (Maxalt) resulted in 2-hour headache resolution in 38% of patients vs 31% with ibuprofen. In two studies, 85 mg of sumatriptan resulted in 2-hour headache resolution in 24% of patients vs 16% with 500 mg of naproxen.
In patients with partial response to triptans, increasing the dose will increase efficacy by 11% or less. Although sumatriptan (oral and intranasal) and eletriptan have demonstrated improved efficacy at higher doses, zolmitriptan has not. The IHS recommends optimizing triptan dosing by ensuring the medication is taken as early as possible and monitoring effectiveness over several migraine episodes.
A triptan is considered effective when it successfully treats 3 of 4 consecutive migraines; switching medications is recommended after failure in 2 of 3 consecutive migraines. The guideline recommends a trial of two other triptans before changing to a different medication class.
Triptans are more effective when combined with fast-release formulations of NSAIDs. Sumatriptan combined with naproxen is supported by the most evidence.
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