Acute Treatment
Triptans and Analgesics:
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Triptans: Effective for migraine treatment, providing pain relief in 42-76% of patients at 2 hours. Combining triptans with acetaminophen or naproxen can enhance efficacy.
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Contraindications: Avoid triptans in individuals with a history of certain conditions, such as stroke, heart attack, and uncontrolled hypertension.
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Analgesics: Acetaminophen, ibuprofen, naproxen, and diclofenac are effective and recommended by the Canadian Headache Society (CHS) for first-line use.
Specific Medications:
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Naproxen: Shown to be superior to placebo in relieving migraine symptoms, including pain, nausea, photophobia, and phonophobia.
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Acetylsalicylic Acid (ASA): Effective, especially in combination with metoclopramide. Effervescent ASA is another viable option.
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Acetaminophen: Proven more effective than placebo, providing relief from migraines and associated symptoms.
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Ibuprofen: Effective, with 400 mg proven to be more effective for a 2-hour reduction in severe to mild or no pain.
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Diclofenac: Tablets and powder formulation are effective, with the powder formulation showing slightly better 2-hour headache freedom.
Parenteral Medications:
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Chlorpromazine, Droperidol, Metoclopramide, Prochlorperazine, Dihydroergotamine, Ketorolac, Magnesium Sulfate: Effective for emergency migraine treatment, especially in an emergency department setting. Opioids are suggested to be avoided.
Nerve Blocks:
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Efficacy: Peripheral nerve blocks, including greater occipital, supratrochlear, and supraorbital nerve blocks, have demonstrated effectiveness in providing long-term improvement and resolution of allodynia.
Neurostimulation:
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Options: Transcutaneous supraorbital nerve stimulation, noninvasive vagal nerve stimulation, and single-pulse transcranial magnetic stimulation are effective for acute migraine treatment. Noninvasive vagal nerve stimulation has FDA approval for migraine treatment.
Calcitonin Gene-Related Peptide (CGRP) Antagonist:
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Role: Antagonism of CGRP, a vasodilator, is a potential treatment option for patients with cardiovascular risk factors.
5HT-1F Agonist:
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Effectiveness: Lasmiditan, a 5HT-1F agonist, has shown superiority to placebo for 2-hour pain relief in phase 3 studies.
These treatments offer a range of options for acute migraine relief, and it's essential to consult with a healthcare professional to determine the most suitable approach based on individual circumstances.
CONSIDERATION IN PREGNANT AND BREASTFEEDING PATIENTS
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Acetaminophen:
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First-line choice: Generally considered safe for pregnant women.
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Concerns: Some studies suggest a possible link to hyperkinetic disorders and ADHD-like behavioral problems, but still considered the safest option during pregnancy by the CHS.
2. Opioids:
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Historically considered safe: Used for pregnant and breastfeeding women.
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Current understanding: Associated with congenital malformations and developmental defects.
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Caution: Codeine use in the third trimester linked to higher risks, including heart malformations and overuse/dependence in mothers.
3. Sumatriptan:
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Lactation: Considered safe according to the American Academy of Pediatrics.
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Pregnancy caution: Some concerns due to 5HT-1B/1D receptors in fetal brain and umbilical cord.
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Findings: Limited evidence suggests no major risks for congenital malformations or developmental issues, but a small increase in preeclampsia risk and potential preterm delivery if used late in pregnancy.
4. NSAIDs (Non-Steroidal Anti-Inflammatory Drugs):
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Risk in pregnancy: Evidence suggests increased risk of adverse fetal outcomes.
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Timing matters: High risk of miscarriage if used early, and potential risks such as cleft lip, premature closure of ductus arteriosus, and neonatal intraventricular hemorrhage if used after 32 weeks.
5. Metoclopramide:
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Safety: Considered safe and preferred for pregnant women with migraine as an antiemetic by the CHS.
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Limited data: Limited information on the safety of other medications like domperidone, ondansetron, and prochlorperazine.
6. Ergots:
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Contraindicated: High risk of adverse fetal outcomes and decreased milk production in pregnancy.
7. Considerations for Providers:
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Balancing risks: Providers should carefully weigh the risks of using medications during pregnancy against the potential harm of not effectively managing headaches and associated disability in women.
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Note: Always consult with a healthcare provider for personalized advice during pregnancy.
Tips for Successful Treatment
Five Tips for Successful Acute Migraine Treatment:
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Accurate Diagnosis:
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Ensure the migraine is correctly diagnosed to tailor the treatment effectively.
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Evidence-Based Approach:
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Use evidence-based recommendations to guide the selection of personalized treatment for the individual.
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Optimize Treatment:
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Maximize the effectiveness of the chosen treatment by adjusting dosage and ensuring proper administration.
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Monitor Response:
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Regularly assess how well the treatment is working to ensure it is providing the desired relief.
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Troubleshoot Ineffectiveness:
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If the treatment is not working as expected, troubleshoot the reasons for suboptimal results.
Bonus Tip:
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Consider using intranasal or injectable forms of medication for patients experiencing nausea, vomiting, or gastroparesis, as these may complicate oral medication effectiveness. Additionally, for fast-onset attacks, opt for medications with a quicker onset of action and shorter time to peak plasma concentration.
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Pharmacology
Pharmacology of Commonly Used Acute Migraine Medications
Treatment Onset (mins) Tmax (hrs) Half-Life (hrs) Max Daily Dose
Triptans
Almotriptan 30–120 1.4–3.8 3.2–3.5 25 mg
Eletriptan 30 1.0–2.0 3.6–5.5 80 mg
Frovatriptan 120–180 2.0–4.0 25 7.5 mg
Naratriptan 60–180 2.0–3.0 5.0–6.3 5 mg
Rizatriptan (tablet) 30–120 1.2 2.0–3.0 30 mg (15 mg if taking propranolol)
Rizatriptan (RPD) 30–12 01.6–2.0 2.0–3.0 30 mg (15 mg if taking propranolol)
Sumatriptan (tablet) 20–30 2.5 2.0 200 mg
Sumatriptan (nasal spray) 15 1.0–1.5 2.0 40 mg
Sumatriptan (nasal powder) 15 0.75 3.0 44 mg
Sumatriptan (injection) 10–15 0.2 1.7–2.0 12 mg
Sumatriptan + Naproxen 20–30 1.0 / 5.0 2.0 / 19.0 2 tablets
Zolmitriptan (tablet) 45 2.0 2.5–3.0 10 mg
Zolmitriptan (orally disintegrating) 45 3.3 2.5–3.0 10 mg
Zolmitriptan (nasal spray) 15 3.0 3.0 10 mg
Ergots
Dihydroergotamine (nasal spray) 30 0.75 __ 104 mg (Max weekly dose: 12 mg)
Simple Analgesics
Acetaminophen 30 0.5–1.0 2.0 4000 mg
ASA (effervescent) 0.3–0.5 0.25—2 __ 600 mg
ASA (tablet)15–30 1.0–2.0 2.0–4.5 (<250 mg), 15–30 (>4000 mg) 4000 mg
Ibuprofen (tablet) 60 1.0–2.0 2.02 400 mg
Naproxen sodium 30 2.0 14 1375 mg
Diclofenac K (tablet) 60 <1.0 2.0 150 mg
Diclofenac K (powder) 15 0.25 2.0 150 mg
Therapeutic Avenues
Domperidone:
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Usage: Trialed during the premonitory phase of migraines.
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Effectiveness: 10-40 mg of domperidone, when taken in the premonitory phase, aborted pain onset in 30 to 63% of attacks. A dose of 30 mg prevented headache onset in 66% of attacks, compared to 5% with a placebo.
Naratriptan:
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Usage: Also used in the premonitory phase.
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Effectiveness: 2.5 mg of naratriptan prevented 60% of migraine headaches in the premonitory phase, as found in an open-label study.
Orexins:
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Role: Hypothalamic neurotransmitter linked to sleep and migraine.
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Trial: Filorexant, an orexin receptor antagonist, was trialed but found to be unsuccessful in migraine treatment.
Octreotide:
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Usage: Beneficial in treating cluster headaches.
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Mechanism: Modulates trigeminovascular pain signaling, secreted by the hypothalamus.
Melatonin:
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Role: Released from the pineal gland, linked to sleep and circadian rhythm.
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Usage: Commonly used in cluster headaches.
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Efficacy: Conflicting evidence on its efficacy in preventing both adult and pediatric migraines despite its association with primary headache disorders.