Acute Migraine Treatment Guidelines

Initial Assessment and Treatment

The American Academy of Neurology recommends ruling out secondary headaches by checking for red flags such as thunderclap headache, atypical aura, head trauma, progressive headache, or headache onset after age 50 3
Evaluate for nausea/vomiting which may require antiemetics and alternative routes of administration 1, 2

The American Headache Society recommends NSAIDs with proven efficacy, including ibuprofen (400mg preferred over 200mg), diclofenac potassium, acetylsalicylic acid (aspirin), and naproxen sodium, as first-line treatment for mild to moderate migraine 1, 2
Acetaminophen is an option only for patients intolerant to NSAIDs 1
Take medication early in the headache phase for maximum effectiveness 1
Triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, or naratriptan) are recommended as second-line treatment for moderate to severe migraine or NSAID failure 1, 2
CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant, are recommended as third-line treatment for triptan failure or contraindication 2, 4

Prokinetic antiemetics (domperidone or metoclopramide) are recommended for nausea/vomiting 1, 2
Consider non-oral routes of administration (subcutaneous, intranasal) for patients with severe nausea/vomiting 2, 5
Preventive therapy should be considered if migraines significantly impact quality of life despite optimized acute treatment, or if patient experiences ≥2 migraine days per month with significant disability 7
First-line preventive options include propranolol, timolol, amitriptyline, and divalproex sodium 8

Re-evaluate treatment effectiveness and adjust as needed 2, 8
Monitor for medication overuse headache, defined as ≥15 days/month with NSAIDs or ≥10 days/month with triptans 2
Consider preventive therapy if attacks remain frequent or severe despite optimal acute treatment 7