Table of Contents
Primary Category
Headache & Pain
P-Category
Secondary Category
S-Category
Introduction
- The abortive (symptomatic) therapy ranges from simple analgesics to migraine-specific drugs.
- Abortive treatment is more effective if it is given early in the course of the headache.
- A large single dose works better than repeated smaller doses.
If abortive therapy is unsuccessful or used more than twice weekly, consider adding prophylactic therapy.
Pharmacological Approach
- Directed mainly by the:
- Severity of the attacks,
- Presence of associated nausea and vomiting,
- Treatment setting (outpatient or medical care facility),
- Patient-specific factors such as vascular risk factors and drug preferences.
Mild to Moderate Attacks
- Attacks not associated with nausea or vomiting;
- Simple analgesics (NSAIDs, acetaminophen)
- Combination analgesics (NSAIDs with Triptans)
- Attacks associated with nausea or vomiting;
- Simple analgesic or combination
- Intramuscular, oral disintegrating tablets or intranasal antiemetics
Moderate to Severe Attacks
- Attacks not associated with nausea or vomiting;
- Oral Triptans or Combination (NSAIDs with Triptans)
- Calcitonin Gene-Related Peptide antagonist
- Ditans
- Attacks associated with nausea or vomiting;
- Nonoral migraine-specific
- Subcutaneous sumatriptan
- Nasal sumatriptan
- Parenteral dihydroergotamine
- Sphenopalatine ganglion block
- Occipital nerve block
Status Migrainosus
- Intravenous Fluids
- Parenteral Medication:
- NSAIDs; Ketorolac
- Dopamine receptor blocker
- Valproate
- Dihydroergotamine; following the Raskin protocol
- Parenteral Dexamethasone is often used to prevent attack relapses
Figure 1: Management of Acute Headache
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Table 1: First-line therapies
Therapy | Drugs and their dose | Major Adverse Effects | Considerations |
Combination Analgesics | Acetaminophen 250 mg/ Aspirin 250 mg: 1 to 2 tablets every 6 hourly. Do not exceed 8 tablets per day. | See individual medications | Available over the counter |
NSAIDS | Ibuprofen: 200 to 800 mg orally every 6 to 8 hours. Do not exceed 2.4 g per day. Naproxen: 250 to 500 mg orally every 12 hours. Do not exceed 1 g per day. | Heartburn, gastric bleeding, ulcers, rebound headaches, renal toxicity, can exacerbate heart failure and hypertension. | Available over the counter. Cannot be used in third trimester of pregnancy |
Triptans | Almotriptan: 6.25 to 12.5 mg orally. Repeated 2 hourly. Do not exceed 25 mg per day. Eletriptan: 20 to 40 mg orally. Repeated 2 hourly. Do not exceed 80 mg per day. Frovatriptan: 2.5 mg orally. Repeated 2 hourly. Do not exceed 7.5 mg per day. Naratriptan: 1 to 2.5 mg orally. Repeated 1-2 hourly. Do not exceed 5 mg per day. Rizatriptan: 5 to 10 mg orally. Repeated 2 hourly. Do not exceed 30 mg per day. Sumatriptan: Intranasal; 5 to 20 mg. Repeated 2 hourly. Do not exceed 40 mg per day. Oral; 25 to 100 mg. Repeated 2 hourly. Do not exceed 200 mg per day. Subcutaneous; 4 to 6 mg. Repeated 2 hourly. Do not exceed 12 mg per day. Zolmitriptan: Intranasal; 5 mg. Repeated 2 hourly. Do not exceed 10 mg per day. Oral disintegrating tablets; 2.5 mg. Repeated 2 hourly. Do not exceed 10 mg per day. Subcutaneous; 1.25 to 2.5 mg. Repeated 2 hourly. Do not exceed 10 mg per day. | Hypertension, vasospasm, chest pain, malaise, fatigue, rebound headache. | Avoid in patients with myocardial infarction, cerebrovascular accident, Prinzmetal angina, uncontrolled hypertension, or other vascular diseases, and in pregnant women. Serotonin syndrome reported on adjunct use with SSRIs. |
Combination Triptans and NSAIDs | Sumatriptan 85mg/ Naproxen 500mg: 1 tablet at onset, can be repeated in 2 hours. Do not exceed 2 tablets per day. | See individual medications | ——— |
Table 2: Other effective therapies
Therapy | Drugs and their dose | Major adverse effects | Considerations |
Antiemetics | Metoclopromide: 10 mg IV every 8 hours Prochlorperazine: 10 mg IV every 8 hours, not to exceed 40 mg per day
Ondansetron: 4mg ODT | Dystonic reaction, parkinsonism with metoclopramide. | ——— |
Steroids | Dexamethasone: 10 to 25 mg IV, one-time dose | Hyperglycemias, mood changes, insomnia: multiple adverse effects with long-term use | Use as adjunctive therapy only |
Ergotamines | Dihydroergotamine: Intranasal; 1 spray in each nostril, repeat once after 15 minutes, do not exceed 4 sprays per attack, 6 sprays per day, 8 sprays per week. IV; 0.5 to 1 mg repeated 8 hours, or continuous IV infusion totalling 3 mg per 24 hours, not to exceed 3 mg per attack. Subcutaneous; 1 mg every hour, do not exceed 3 mg per day. | Nausea, rhinorrhea with intranasal use | IV dosing can be used in combination with 10 mg metoclopramide every 8 hours as needed for nausea. |
Isometheptene | Acetaminophen 325mg/dichlorphenazone,100mg/isometheptene, 65mg: 1 to 2 capsules orally every 4 hours. Do not exceed 8 capsules per day | ——— | Use with caution in patients with cardiovascular risk factors. |
Local Anaesthetic | Lidocaine: Intranasal; 0.5 ml of topical lidocaine 4% solution dripped into nostril on the affected side over 30 seconds | Rare cardiac if absorbed systemically. | Symptoms may recur. |
Further Reading
- Recurrence of primary headache disorders after emergency department discharge: frequency and predictors of poor pain and functional outcomes. Ann Emerg Med 2008;52(6):696Y704. doi:10.1016/ j.annemergmed.2008.01.334.
Bibliography
- Walling, L. M. (2018, February 15). Acute migraine headache: Treatment strategies. AAFP American Academy of Family Physicians. https://www.aafp.org/afp/2018/0215/p243.html
- Recurrence of primary headache disorders after emergency department discharge: frequency and predictors of poor pain and functional outcomes. Ann Emerg Med 2008;52(6):696Y704. doi:10.1016/ j.annemergmed.2008.01.334.
- Gelfand, A. A., & Goadsby, P. J. (2012). A Neurologist’s Guide to Acute Migraine Therapy in the Emergency Room. The Neurohospitalist, 2(2), 51–59. https://doi.org/10.1177/1941874412439583
- VanderPluym, J. H., Halker Singh, R. B., Urtecho, M., Morrow, A. S., Nayfeh, T., Torres Roldan, V. D., Farah, M. H., Hasan, B., Saadi, S., Shah, S., Abd-Rabu, R., Daraz, L., Prokop, L. J., Murad, M. H., & Wang, Z. (2021). Acute Treatments for Episodic Migraine in Adults. JAMA, 325(23), 2357. https://doi.org/10.1001/jama.2021.7939
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