Acute Migraine Management in Adults

First‑Line Treatment Strategy

• For adults with acute moderate‑to‑severe migraine, initiate a combination of a triptan and an NSAID (or acetaminophen if NSAIDs are contraindicated) as early as possible after symptom onset. 1
• Mild‑to‑moderate migraine attacks can be treated with an NSAID alone (e.g., ibuprofen, naproxen sodium, diclofenac potassium, aspirin) or acetaminophen. 3
• Moderate‑to‑severe migraine attacks should receive triptan + NSAID combination therapy from the outset. 5
• Starting treatment promptly after headache onset improves efficacy compared with delayed administration. 5

Choice of Triptan

• Select a triptan based on patient preference for route of administration and cost considerations. 2

Choice of NSAID

• If NSAIDs are contraindicated, combine the chosen triptan with acetaminophen. 3

Adjunctive Antiemetic Therapy

• In patients with severe nausea or vomiting, add an antiemetic and consider a non‑oral triptan formulation (nasal spray or subcutaneous injection). 2

Second‑Line Options for Inadequate Response

• CGRP receptor antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant may be used when triptan + NSAID therapy fails. 5
• Dihydroergotamine (an ergot alkaloid) is an alternative rescue option. 5
• Lasmiditan (a ditan) is reserved for patients who have failed all other acute therapies. 5

Contraindications and Prohibited Agents

• Triptans should be avoided in patients with coronary artery disease. 4
• Opioids and butalbital‑containing compounds are not recommended for acute migraine treatment. 1

Medication‑Overuse Headache (MOH) Prevention

• Limit NSAID use to fewer than 15 days per month. 4
• Limit triptan use to fewer than 10 days per month. 4
• If acute medication use exceeds these thresholds, initiate preventive therapy. 4

Common Clinical Pitfalls

• Ensure patients receive the appropriate dose of triptan or NSAID before labeling therapy as a failure; dose escalation within approved limits is acceptable. 3
• Emphasize early administration at headache onset rather than waiting for peak severity. 5
• Patients who do not respond to one triptan or NSAID may benefit from trying a different agent within the same class. 2
• Prescribing opioids for acute migraine is discouraged due to increased risk of medication‑overuse headache. 1

Special Populations: Pregnancy

• Acetaminophen is the safest acute migraine medication during pregnancy. 4
• NSAIDs may be used safely before the third trimester. 2
• Sumatriptan can be considered in selected pregnant patients when benefits outweigh risks. 4
• Discuss risks and benefits of all pharmacologic options with patients of child‑bearing potential. 2