Acute Migraine Treatment Guidelines

First-Line Treatment Options

• The American Academy of Neurology recommends NSAIDs as the first-line treatment for mild to moderate migraine attacks, with strong evidence supporting acetylsalicylic acid, ibuprofen, naproxen sodium, and diclofenac potassium 1, 3
• The American Headache Society suggests that triptans are the first-line treatment for moderate to severe migraine attacks or when NSAIDs fail, with sumatriptan being a commonly used option 1, 2, 3

Second-Line and Combination Approaches

• The American Academy of Neurology recommends combining a triptan with an NSAID for patients experiencing inadequate relief with a single agent, providing superior efficacy 1, 2, 4
• The American Headache Society suggests that if one triptan is ineffective, trying another triptan may provide relief 1, 4

Third-Line Options for Refractory Migraine

• The American Academy of Neurology recommends ditans, such as lasmiditan, as a third-line option for refractory migraine, with efficacy comparable to triptans but potential for driving impairment 1
• The American Headache Society suggests that gepants, such as rimegepant and ubrogepant, are CGRP antagonists that can be used for patients who don't respond to or cannot tolerate triptans 2

Important Considerations and Cautions

• The American Academy of Neurology recommends starting treatment as early as possible during the attack to improve efficacy 3
• The American Headache Society suggests that acute treatments should be limited to no more than twice weekly to prevent medication overuse headache 2, 3, 4

Special Populations

• The American Academy of Neurology recommends considering non-oral routes of administration or adding antiemetics for patients with significant nausea or vomiting 3, 4