Migraine Headache: Acute Treatment

Acute treatment of migraine should target both head pain and, if present, associated symptoms such as nausea and vomiting. The latter may limit absorption of oral medications; in these cases, intranasal or subcutaneous formulations may be useful in the outpatient setting, and intravenous formulations in the hospital setting. Abortive medications are most effective when taken early in the migraine attack. Supportive measures should include aggressive hydration and rest or sleep when feasible. Caffeine may potentiate the effects of abortive medications and often helps relieve migraine. In general, use of abortive medications should be limited to 2–3 days per week to avoid medication overuse headache. Emerging alternatives to abortive medications include neurostimulation and occipital or other cranial nerve blocks with anesthetics; these may be particularly useful in patient for whom specific medications are ineffective or contraindicated.

A.

In the hospital setting, the range of options for migraine treatment is broad due to the ability to give parenteral agents. Selection of therapy depends on which agents may have already been used in an attempt to abort headache, prior history of response or lack of response to particular agents, and potential contraindications to specific medications. In patients who have not already tried a triptan, subcutaneous sumatriptan and metoclopramide are a reasonable choice for initial therapy. Prochlorperazine or chlorpromazine can be used as alternatives to metoclopramide. When given parenterally, all three of these antiemetics have efficacy for relieving headache as well as associated nausea/vomiting. Pretreatment with diphenhydramine helps to prevent extrapyramidal side effects from these drugs. Ondansetron may be a more efficacious antiemetic but does not seem to have antimigraine effects. For patients previously unresponsive to triptans or who have not been able to abort their current migraine with a triptan, intravenous dihydroergotamine (DHE) can be an effective treatment strategy, but should not be used if a triptan has been administered within the previous 24 hours. DHE is contraindicated in patients with hemiplegic migraine, basilar migraine, cardiovascular disease, and severe renal or hepatic impairment. DHE should not be used within 2 weeks of monoaminoxidase inhibitors due to risk of serotonin syndrome. Finally, monotherapy with parenteral metoclopramide (prochlorperazine or chlorpromazine are alternatives) can be used if a patient has taken a triptan within 24 hours of presenting to the emergency department (ED) or has contraindications to triptans or DHE (Table 65.1).
B.

When severe nausea or vomiting are present, subcutaneous sumatriptan should be used. It can be easily self-administered by patients at home. This is often effective at treating both the headache and nausea. If not, an antiemetic such as metoclopramide may be given as adjunctive therapy. Intranasal sumatriptan or zolmitriptan can also be considered in this situation, but nasal sprays can be difficult to tolerate in the presence of nausea.
C.

Triptans should be used as a first-line abortive therapy for severe migraine headache, and can also be used when pain is moderate but does not respond to simple or combination analgesics. Subcutaneous and intranasal formulations have faster onset of action (10–20 min) and are preferred for headaches that are severe at the beginning of the attack or are present in the morning upon awakening. Eletriptan and rizatriptan appear to be the most effective oral triptans, but also may have more side effects. Almotriptan is often better tolerated with reasonable efficacy. Naratriptan has a slower onset of action and tends to have the least side effects. Frovatriptan has a longer half-life and should be considered if the pain usually returns within 24 hours. Importantly, response to individual triptans varies across patients, and it is reasonable to switch to a different triptan before trying other classes of medications. Triptans are contraindicated in patients with hemiplegic migraine, basilar migraine, or cardiovascular disease. Common side effects are dizziness, fatigue, flushing, tingling, and chest pain.
D.

Combining a triptan with a nonsteroidal antiinflammatory drug (NSAID) has been shown to be more effective than either used as a monotherapy, and should be considered if triptans alone are ineffective.
E.

Not infrequently, migraine headache will initially respond to intravenous therapy in the ED, but subsequently recur within 24 hours. Administration of a single dose of intravenous dexamethasone reduces the risk of headache recurrence and should be considered for most patients treated for headache in the ED.
F.

In patients for whom triptans and DHE are contraindicated, simple analgesics, combination analgesics, occipital and other cranial nerve blocks with anesthetics, and neurostimulation devices are alternatives available in the outpatient setting. Neurostimulation devices for acute migraine treatment include transcutaneous trigeminal nerve stimulation, noninvasive vagus nerve stimulation, and transcranial magnetic stimulation. The use of butalbital-containing analgesic combinations (Fioricet and Fiorinal) is discouraged due to concerns of medication overuse headache. However, they may be considered when all other options are contraindicated or ineffective as long as they are used sparingly.