Management of acute treatment of migraine

NICE suggest acute treatment (1)

• offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol, for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events
• for people who prefer to take only 1 drug, consider monotherapy with an oral triptan, NSAID, aspirin (900 mg) or paracetamol for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events
  • note that because of the association with Reye's syndrome, preparations containing aspirin should not be offered to under 16s
• for young people aged 12-17 years consider a nasal triptan in preference to an oral triptan
• consider an anti‑emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting.
• for people in whom oral preparations (or nasal preparations in young people aged 12 to 17 years) for the acute treatment of migraine are ineffective or not tolerated:
  • consider a non‑oral preparation of metoclopramide or prochlorperazine and
  • if non-oral metoclopramide or prochlorperazine is used, consider adding a non‑oral NSAID or triptan if they have not been tried
    • note the special warnings and precautions for use in the summaries of product characteristics for metoclopramide and prochlorperazine, and discuss the benefits and risks with the person (or their parents or carers, as appropriate).
• rimegepant (an oral calcitonin gene-related peptide [CGRP] inhibitor placed on or under the tongue) is recommended as an option in NICE technology appraisal guidance for the acute treatment of migraine with or without aura in adults, only if for previous migraines:
  • at least 2 triptans were tried and they did not work well enough or
  • triptans were contraindicated or not tolerated, and NSAIDs and paracetamol were tried but did not work well enough
• do not offer ergots or opioids for the acute treatment of migraine

These acute interventions are best taken early in the attack when absorption may be least inhibited by gastric stasis. These drugs should be used without codeine or dihydrocodeine (2)

• codeine and dihydrocodeine are used extensively in OTC combination analgesics;
  • they provide small additional benefit in a range of painful conditions but evidence of this does not extend to headache and it is at the expense of increased side-effects
  • also these drugs are frequently implicated in medication overuse headache

An anti-emetic such as metoclopramide or domperidone not only relieves nausea that accompanies may migraine attacks but also enhances the efficacy of simultaneously administered oral analgesics (3).

Note that because triptans are agonists for receptors of multiple 5-HT subtypes, they can cause vasoconstriction and are contraindicated in patients with known or suspected vasospastic or ischemic vascular disorders and in patients with uncontrolled hypertension (4)

• adverse effects include limb heaviness; flushing; paresthesia; and tightness in the chest, neck, or throat
  • these effects are almost always benign and can be mitigated by reducing the dose, switching to an alternative triptan, or treating earlier in the attack

Consult the respective Summary of Product Characteristics before prescribing of the medication mentioned.

Reference:

1. NICE (June 2025). Headaches - Diagnosis and management of headaches in young people and adults
2. British Association for Study of Headache guidelines, 2004.
3. Drug and Therapeutics Bulletin 1998; 36(6):41-4.
4. Niushen Zhang, Matthew S. Robbins. Migraine. Ann Intern Med. [Epub 10 January 2023]. doi:10.7326/AITC202301170