What are the AHS guidelines on the treatment of migraine variants (equivalents)?

Updated: Oct 16, 2019
  • Author: Rima M Dafer, MD, MPH, FAHA; Chief Editor: Helmi L Lutsep, MD  more...
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Emergency department treatment

In 2016, the American Headache Society (AHS) released guidelines for the management of adults with acute migraine in the emergency department. They recommend intravenous metoclopramide, intravenous prochlorperazine, and subcutaneous sumatriptan to treat these patients (level B recommendation). Dexamethasone should be offered to these patients to prevent recurrence of headache (level B). Opioids (injectable morphine and hydromorphone) should be avoided. [76, 77]

An updated position statement from AHS in 2019 offers guidance on preventive and acute treatment of migraine. [78]  Recommendations include:

Preventive migraine treatment

Consider preventive treatment for migraine patients in any of the following situations:

  • Migraine attacks are frequent (≥4 migraine headache days per month) and/or the attacks interfere with patients’ daily routines even with acute treatment
  • There is contradiction to, failure, or overuse of acute treatments
  • Acute treatments lead to adverse events

Oral treatments should be offered for migraine prevention. These include antiepileptic drugs, beta-blockers, and frovatriptan. Do not prescribe valproate sodium and topiramate to women who are not using birth control and who may become pregnant.

Start oral treatments at a low dose and titrate slowly.

Give oral treatments for at least 8 weeks to optimize therapeutic response.

Acute migraine treatment

Use evidence-based treatment at the first sign of a migraine attack.

Use NSAIDs (including aspirin), nonopioid analgesics, acetaminophen, or caffeinated analgesic combinations for mild‐to‐moderate attacks and migraine‐specific agents (triptans, dihydroergotamine) for moderate or severe attacks and mild‐to‐moderate attacks that respond poorly to NSAIDs or caffeinated combinations. 

Use a nonoral option for select patients, including those with nausea or vomiting or those who have trouble swallowing.

Options for outpatient rescue include SC sumatriptan, DHE injection or intranasal spray, or corticosteroids. Inpatient options may include parenteral formulations of triptans, DHE, antiemetics, NSAIDs, anticonvulsants (eg, valproate sodium and topiramate, except in women of childbearing age who are not using reliable birth control), corticosteroids, and magnesium sulfate.

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