Acute Migraine Headache Medication

Aka: Acute Migraine Headache Medication, Migraine Abortive Medication, Migraine Abortive Treatment, Migraine Abortive Management

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II. Management: General Pointers

  1. Follow a stepped strategy of Migraine medication
    1. See Acute Migraine Headache
  2. Consider abortive agent sparing measures
    1. See Headache General Measures
    2. See Migraine Prophylaxis
    3. Establish Migraine Management Clinic Schedule
    4. Consider Migraine Headache Prophylaxis
      1. Frequent Migraine Headaches (4/month, 8 days/month)
      2. Prolonged Headaches >2 days with Disability
      3. Debilitating Headache despite acute Migraine abortive agents
      4. Intolerance or contraindications to acute Migraine abortive agents
      5. Analgesic Overuse Headaches or overuse of acute Migraine abortive agents
      6. Complicated Migraine Headache subtypes with prominent neurologic findings
  3. Evaluate acute Headache regimen with standardized symptom score
    1. Migraine Treatment Optimization Questionnaire (M-TOQ)
      1. https://www.mdcalc.com/calc/10496/migraine-treatment-optimization-questionnaire-mtoq-4
      2. Lipton (2009) Cephalalgia 29(7):751-9 [PubMed]
      3. Serrano (2015) Headache 55(4):502-18 [PubMed]
    2. Migraine Assessment of Current Therapy (Migraine-ACT)
      1. Dowson (2004) Neurol Sci 25 Suppl 3:S276-8 +PMID:15549559 [PubMed]
      2. Kilminster (2006) Headache 46(4):553-62 [PubMed]
  4. Avoid use of abortive agents more than twice per week
    1. Frequent use results in Rebound Headache
    2. NSAIDs are unlikely to cause Rebound Headache
  5. Gastrointestinal motility drugs improve efficacy
    1. Metoclopramide (Reglan)
      1. Dose: 10 mg PO 20-30 minutes before pre-medication
      2. Extrapyramidal Side Effects
        1. Dystonic Reaction (especially in children)
      3. Antiemetic effect in addition to increased motility
  6. Antiemetics may be very useful in abortive treatment
    1. Alleviate Nausea associated with Headache
    2. Sedation to allow rest despite Headache
    3. Increases medication absorption (e.g. Reglan)
  7. Combined therapies may be helpful in refractory cases
    1. Aspirin and Metoclopramide
      1. Aspirin 975 mg PO (three 325 mg tablets)
      2. Metoclopramide (Reglan) 10 mg PO
    2. DHE and Vistaril Combination
      1. DHE-45 1 mg IM
      2. Vistaril 75 mg IM

III. Medications: Serotonin Agonists

  1. See Acute Migraine Headache
  2. Triptans may have inadequate response in up to one third of Migraine Headache patients
    1. Consider switching to another Triptan
    2. Consider combining with NSAIDs
    3. Consider Rebound Headache or other Headache Causes
    4. Consider third-line agents (see below)
  3. Triptans (preferred over Ergotamines)
    1. Sumatriptan (Imitrex)
    2. Rizatriptan (Maxalt)
    3. Zolmitriptan (Zomig)
    4. Naratriptan (Amerge)
  4. Ergotamines (do not use within 24 hours of Triptans)
    1. Dihydroergotamine (DHE-45)
    2. Ergotamine

IV. Medications: Oral Analgesics

  1. See Acute Migraine Headache
  2. General
    1. Beware Rebound Headaches with the frequent use of most Analgesics
  3. Analgesics with proven efficacy
    1. Excedrin Migraine (Acetaminophen, Aspirin, Caffeine)
    2. Aspirin 975 mg PO (with or without Metoclopramide)
    3. Midrin (Isometheptene, Dichloralphenazone, Tylenol)
      1. Dose: 2 stat at Headache onset
      2. Repeat 1 each hour prn
      3. Maximum: 5 pills per 12 hours, 20 pills per month
      4. Limit use to no more than 2 days per week
    4. Anaprox, Aleve (NaproxenSodium)
      1. Absorbed more rapidly than Naprosyn
      2. Initial Dose: 825 mg (Three 275 mg tablets)
      3. Repeat 220 to 550 mg every 3-4 hours
      4. Maximum: 1.5 grams per day (5 to 6 tablets per day)
  4. Analgesics to be avoided (low efficacy and higher risk)
    1. Cafergot (Ergotamine with Caffeine)
      1. Dose: 2 PO stat with Headache onset
      2. Repeat one tablet every half hour prn
      3. Maximum: 4 to 6 pills per day or 10 per week
    2. Fiorinal (ASA 325mg, Caffeine 40mg, Butalbital 50mg)
      1. Dose: 2 tablets at Headache onset
      2. Repeat one tablet every 4 to 6 hours prn
      3. Maximum: 5 pills per day or 15 per month
      4. Limit use to no more than 2 days per week
      5. Risk of Rebound Headaches with use more than 5 days per month
    3. Esgic or Fioricet (Tylenol, Caffeine, Butalbital)
      1. Same dosing recommendations and precautions as for Fiorinal
      2. Precaution: Pharmaceutical obfuscation alert
        1. Fioricet brand name capsules (Watson) as of 2014 will contain 300 mg Acetaminophen (at 4x the generic cost)
        2. Fioricet generic tablets will contain 325 mg Acetaminophen (making automatic substitution difficult)
        3. One more reason not to prescribe fioricet (other Migraine abortive agents are preferred)
        4. (2014) Presc Lett 21(3)

V. Medications: ParenteralAnalgesics

  1. See Emergency Department Migraine Headache Care
  2. See Serotonin Agonists (Triptans) below
  3. See Opioids below (avoid if possible)
  4. Ketorolac (Toradol)
    1. Dose: 30-60 mg IM
    2. May repeat 15-30 mg q6h
    3. Do not exceed 5 consecutive days of use
    4. May supplement with rectal Antiemetic

VI. Medications: Rectal Analgesics (indicated for Vomiting)

  1. Rectal Antiemetics
    1. Promethazine (Phenergan) 12.5 to 25 mg PR q4-6 hours
    2. Prochlorperazine (Compazine) 25 mg PR q12 hours
  2. Rectal Analgesics
    1. Indomethacin 50 mg, 1-2 PR at Headache onset
  3. Serotonin Agonist
    1. Ergotamine tartrate (Wigraine) suppository
    2. Use Ergotamine with caution due to adverse effects

VII. Medications: Third-line Agents

  1. Precautions
    1. Expensive agents ($85 per tablet in 2020)
    2. Half the efficacy than Triptans
  2. Indications
    1. Indicated in Migraines refractory to at least two first-line Triptans
    2. Evaluate efficacy with standardized symptom score (see above)
  3. Gepant (CGRP receptor blocker)
    1. Ubrogepant (Ubrelvy)
    2. Rimegepant (Nurtec)
    3. Zavegepant (Zavzpret)
  4. Ditan (Selective Serotonin 5-Hydroxytryptamine receptor 1F agonst or 5-HT1F Agonist)
    1. Schedule V due to euphoria and Hallucinations
    2. Lasmiditan (Reyvow)

VIII. Medications: Opioids

  1. Generally avoid Opioids in chronic Headache Management
  2. Indications
    1. Patients failing every other non-Opioid therapy and Migraine Prophylaxis despite neurology Consultation
    2. Least desirable for Headache Management
      1. Non-specific for Headache
      2. Higher risk for Rebound Headache
      3. Addictive potential (Substance Misuse)
  3. Stadol-NS (Butorphanol)
    1. Addictive (Class IV regulated substance)
      1. High abuse potential
    2. Dosing
      1. Stadol 1 spray in one nostril, repeat hourly prn
      2. Maximum 4 sprays per day or 6 sprays per week
      3. Limit to 2 days per week

IX. Medications: Other Non-Pharmacologic Measures

  1. Greater Occipital Nerve Block
  2. Neuromodulatory Devices
    1. Noninvasive Vagus Nerve stimulation
    2. Remote electrical neuromodulation
  3. Avoid measures without strong evidence in acute Migraine Management
    1. Acupuncture
    2. Electrical Trigeminal Nerve stimulation
    3. Single-Pulse transcranial magnetic stimulation

X. Contraindications: Vasocontrictors (e.g. Triptans, DHE)

  1. Contraindications to Vasoconstrictors (e.g. Triptan, DHE)
    1. Coronary Artery Disease
    2. Cerebrovascular Accident history
    3. Hemiplegic Migraines
    4. Basilar Migraines
    5. Pregnancy
  2. Alternative Non-Vasoconstrictive agents
    1. Excedrin Migraine (Acetaminophen, Aspirin, Caffeine)
    2. NSAIDS
    3. Dopamine Antagonists (e.g. Metoclopramide or Prochlorperazine)
    4. Gepant (CGRP receptor blocker, e.g. Ubrogepant, Rimegepant, Zavegepant)
    5. Ditan (e.g. Lasmiditan)

XI. References

  1. (1995) Med Lett Drugs Ther 37(943) [PubMed]
  2. Moore (1997) Am Fam Physician 56(8):2039-48 [PubMed]
  3. Jackson (1998) CMEA Internal Medicine Lecture,San Diego
  4. Noble (1997) Am Fam Physician 56(9):2279-86 [PubMed]
  5. Wiley (2025) Am Fam Physician 111(4): 317-27 [PubMed]

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