Acute treatment of migraine in adults without hemiplegic or brainstem aura

Pharmacologic treatment of nonpregnant adults with acute migraine should be given early following symptom onset to maximize efficacy and reduce the risk of adverse effects and medication overuse headache. The selection of a specific agent depends on patient-specific factors including the severity and character of symptoms, comorbid conditions, and prior response to treatment. Repeat dosing may be required for patients who report inadequate relief with initial therapy. Parenteral options with or without an antiemetic agent may be preferred for faster onset of efficacy and for patients with severe nausea/vomiting who are unable to tolerate oral options. Adjunctive prophylactic treatment may be started for patients with headaches that are frequent, long-lasting, and/or disabling. Refer to UpToDate topics for additional details.

OTC: over the counter (nonprescription); triptan: serotonin 1b/1d agonist; CGRP: calcitonin gene-related peptide; DHE: dihydroergotamine.

* Triptans and DHE should be avoided in patients with hemiplegic migraine or migraine with brainstem aura and those with a history of ischemic stroke, vaso-occlusive arterial disease, and uncontrolled hypertension. Initial dose for most triptan formulations may be repeated in two hours; refer to Lexicomp drug monographs for product-specific details. Triptans or DHE should not be started within 24 hours of the use of an alternative ergotamine or a different triptan agent.

¶ Dopamine receptor blocking antiemetic agents are typically used along with diphenhydramine to prevent akathisia and acute dystonic reactions. In addition, oral or intravenous fluids should also be administered to patients with suspected volume depletion due to reduced oral intake and/or recurrent vomiting. Dopamine blockers can lead to cardiac arrhythmias and should be avoided in patients with congenital or acquired long QT syndrome.

Δ Adjunctive dexamethasone is given to reduce the frequency of early migraine recurrence, but use should be limited to patients with refractory migraine, status migrainosus, and those with a history of frequent recurrent migraine attacks to reduce the risk of adverse effects. Refer to UpToDate for additional details.

◊ Lasmiditan may cause dizziness and/or somnolence; patients should not drive a motor vehicle or otherwise engage in potentially hazardous activities for at least eight hours after use of lasmiditan.

§ Initial dose of ubrogepant may be repeated in two hours. The safety of CGRP antagonists within two to four hours of a triptan or DHE is not well established.

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Acute treatment of migraine in adults without hemiplegic or brainstem aura