Acute Migraine Treatment Guidelines

First-Line Treatments

The American College of Physicians recommends starting with NSAIDs (aspirin, celecoxib, diclofenac, ibuprofen, or naproxen) or acetaminophen at appropriate dosages for mild to moderate migraine attacks 1, 3
Combination therapy of an NSAID plus acetaminophen may be considered for enhanced efficacy in mild to moderate migraine attacks 1, 3
Ensure adequate dosing before concluding treatment failure, considering increasing the dose without exceeding maximum daily recommendations 1

For patients who don't respond to or cannot tolerate first-line options, consider CGRP antagonists (gepants: rimegepant, ubrogepant, zavegepant) or dihydroergotamine 1, 2
The ditan lasmiditan may be used when patients don't respond to all other pharmacologic treatments 1, 2

Acetaminophen is the safest first-line option during pregnancy 6
Medication overuse headache occurs when acute medications are used too frequently (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1, 3

Never use opioids or butalbital for acute migraine treatment due to risks of dependency and medication overuse headache 1, 2, 5
Triptans are contraindicated in patients with cardiovascular disease due to their vasoconstrictive properties 4

Lifestyle modifications, such as staying well hydrated, maintaining regular meals and sleep patterns, engaging in regular physical activity, and managing stress, are important adjuncts to pharmacological treatment 1, 3
Identify and avoid individual migraine triggers 1, 6