Acute Migraine Treatment Guidelines

First-Line Treatment

The American College of Physicians recommends starting with oral NSAIDs or acetaminophen as monotherapy for mild-to-moderate migraine attacks, with specific NSAIDs having strong evidence including aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 2
For moderate-to-severe migraine, initiate combination therapy with a triptan plus NSAID, which is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1, 2, 3
Administer treatment as early as possible in the attack while pain is still mild, with oral route preferred for most patients 1, 2, 4

For patients not responding to triptan-NSAID combination, consider CGRP antagonists (gepants: rimegepant, ubrogepant, zavegepant) or dihydroergotamine, with dihydroergotamine having good efficacy evidence 1, 2, 3
Lasmiditan (ditan) is reserved for patients failing all other treatments 1, 2

Limit all acute migraine medications to a maximum of 2 days per week (10 days per month) to prevent medication-overuse headache, with NSAIDs causing medication-overuse headache if used ≥15 days/month and triptans if used ≥10 days/month 1, 2, 3
If needing acute treatment more than twice weekly, immediately initiate preventive therapy 3, 4

Do not use opioids or butalbital-containing compounds for acute migraine treatment, as opioids lead to dependency, rebound headaches, and loss of efficacy 1, 2, 3, 4

Acetaminophen is the safest option during pregnancy, and sumatriptan may be an option for selected pregnant patients and is compatible with breastfeeding 1, 2
Discuss adverse effects of all pharmacologic treatments with patients of childbearing potential 1, 2

Inadequate dosing before declaring treatment failure, delayed administration, not combining triptan with NSAID, allowing escalation of acute medication frequency, and using opioids routinely are common pitfalls to avoid in acute migraine treatment 1, 2, 3, 4