The American Headache Society Position Statement on Integrating New Migraine Treatments Into Clinical Practice

American Headache Society



In This Article

Acute Treatment

The following are goals of acute migraine treatment:[22]

  • Rapid and consistent freedom from pain and associated symptoms without recurrence

  • Restored ability to function

  • Minimal need for repeat dosing or rescue medications

  • Optimal self-care and reduced subsequent use of resources (eg, emergency room visits, diagnostic imaging, healthcare provider and ambulatory infusion center visits)

  • Minimal or no AEs

Effective acute treatment can reduce the pain, associated symptoms, and disability associated with attacks. Suboptimal acute treatment leads to an increase in migraine-related disability and disease progression.[59]

Indications for Acute Treatment

All patients with migraine should be offered a trial of acute treatment. The following principles may help to improve outcomes in patients with migraine.[22]

Developing Treatment Plans

Use evidence-based treatments. Use NSAIDs (including aspirin), nonopioid analgesics, acetaminophen, or caffeinated analgesic combinations (eg, aspirin + acetaminophen + caffeine) for mild-to-moderate attacks and migraine-specific agents (triptans, dihydroergotamine [DHE]) for moderate or severe attacks and mild-to-moderate attacks that respond poorly to NSAIDs or caffeinated combinations. Treat at the first sign of pain to improve the probability of achieving freedom from pain and reduce attack-related disability. Acute treatments considered effective or probably effective based on a 2015 American Headache Society expert review of evidence from controlled trials[18] are presented in Table 7.

Choose a nonoral route of administration for severe nausea or vomiting. Use a nonoral formulation in patients whose attacks are associated with severe nausea or vomiting or who have trouble swallowing orally administered medications. This includes sumatriptan 3, 4, or 6 mg SC and intranasal and inhaled powder formulations and ketorolac in intranasal and intramuscular (IM) formulations.[60–64] Dihydroergotamine SC and intranasal spray are alternatives. Consider IV DHE and an antiemetic for especially refractory headaches. In addition, antiemetics, such as prochlorperazine suppositories (for both headache and nausea), may be useful. Nonoral routes of administration should also be considered in patients who do not respond well to traditional oral treatments or experience significant nausea or vomiting early during attacks.

Account for tolerability and safety issues. The tolerability and safety of certain acute treatments may preclude usage in sensitive patients and those with certain coexistent or comorbid illnesses. For instance, NSAIDs can cause serious gastrointestinal and cardiovascular side effects; triptans and ergotamine derivatives should be avoided or used with caution in patients with coronary artery disease, peripheral vascular disease, uncontrolled hypertension, and other vascular risk factors and disorders. Failure to account for tolerability and safety issues in prescribing may cause patients to limit, delay, or forego acute treatment altogether.[65]

Consider self-administered rescue. When first-line acute treatment does not bring relief, patients may require rescue medication. Depending on the initial treatment, options for outpatient rescue include SC sumatriptan, DHE injection or intranasal spray, or corticosteroids (eg, dexamethasone, IM ketorolac); inpatient options may include parenteral formulations of triptans, DHE, antiemetics, NSAIDs (eg, ketorolac), anticonvulsants (eg, valproate sodium and topiramate [not in women of childbearing potential who are not using an appropriate method of birth control[34,35]]), corticosteroids, and magnesium sulfate. Consider recommending a self-administered rescue treatment for patients with severe attacks and those who have a history of nonresponse or variable response to acute treatment.

Avoid medication overuse. Migraine patients who need to use acute treatments on a regular basis should be instructed to limit treatment to an average of 2 headache days per week, and patients observed to be exceeding this limit should be offered preventive treatment.[18] Patients who have medication overuse despite the use of preventive treatment may require an escalation in dose, a change in preventive therapy, or the addition of another preventive treatment including but not limited to established drugs, biologics, neuromodulation, and biobehavioral approaches.

Measuring Response to Acute Treatment

Response to acute treatment of migraine can be assessed in many ways, but the efficacy endpoints typically used in clinical trials may not fully reflect the outcomes valued by patients[66–68] or the need for ease of use in clinical practice. Failure to understand patient preferences may reduce adherence, discourage patients from continuing treatment, and limit the ability to match treatment with patient needs. As with preventive treatment, patient-oriented, validated outcome measures of acute treatment success can help to verify that patients have experienced a meaningful response and identify the need for adjustments to a therapeutic regimen. For acute treatment, examples of these measures are listed in Appendix B.