4.7.4.1 Treatment of acute migraine

ChoiceDrugDosage
1st choicesIbuprofen tablets 200mg, 400mg, 600mgDose:
400 mg to 600 mg every 4-6 hours, no more than four doses in 24 hours.
Or

Paracetamol tablets 500mg; soluble tablets
Plus oral triptan (see choice below)

Dose:
1 g every 4–6 hours, no more than four doses in 24 hours
1st choice triptanSumatriptan tablets 50mg, 100mgDose:
50-100mg as soon as possible after onset of headache; dose may be repeated after not less than 2 hours if migraine recurs; max 300mg in 24 hours
2nd choice triptanAlmotriptan tablets 12.5mgDose:
12.5mg as soon as possible after onset repeated after 2 hours if migraine recurs; max 25mg in 24 hours
  • Offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol.
  • If monotherapy is preferred, offer an oral triptan, or NSAID or aspirin (900mg every 4-6 hours when necessary up to a max 4g daily), or paracetamol.
  • Consider adding an anti-emetic (see notes below) even in the absence of nausea and vomiting.

Prescribing Notes

Standard Analgesics/NSAIDs

  • Most patients with true migraine have gastric stasis during an acute attack. Soluble/dispersible tablets are particularly useful in migraine as they are absorbed quickly and have a more rapid effect than non-dispersible tablets.
  • Paracetamol suppositories or diclofenac suppositories (off label) may be useful for pain relief if vomiting occurs during migraine.
  • Do NOT use ergots or opioids.
  • Chronic overuse of aspirin, paracetamol, or co-codamol may cause medication overuse headache. Chronic overuse of analgesics should therefore be avoided.
  • Some patients may be at increased risk of experiencing toxicity at therapeutic doses of paracetamol, particularly those with a body-weight under 50 kg and those with risk factors for hepatotoxicity. Clinical judgement should be used to adjust the dose of oral and intravenous paracetamol in these patients.

Anti-emetics

  • Consider adding an anti-emetic such as metoclopramide, domperidone or prochlorperazaine (see section 4.6).
  • Anti-emetics have an independent action on migraine, so can be considered even if nausea or vomiting are not present.
  • If vomiting restricts oral treatment, consider buccal prochlorperazine tablets.
  • Metoclopramide can cause acute dystonic reactions especially in patients under 20 years of age. It can be prescribed for short term use (up to 5 days) for the symptomatic treatment of nausea and vomiting associated with acute migraine (where it may also be used to improve absorption of oral analgesics). Click here for further information.
  • Domperidone is associated with a small increased risk of serious cardiovascular side effects. Its use is now restricted to the relief of symptoms of nausea and vomiting. Treatment is not recommended for longer than one week (maximum of 10mg three times a day). Domperidone is now contraindicated in those with underlying cardiac conditions and other risk factors Click here for more information.

Triptans

  • Medication should be taken as early as possible after migraine headache starts, but not during the aura phase. Headache recurrence within the first 24 hours can be treated with a second dose.
  • Sumatriptan 50mg is recommended as first line choice. The 100mg dose has more adverse effects and is only marginally more effective.
  • If the first dose of a triptan fails to help, alternative medication should be considered.
  • If treatment with sumatriptan proves to be inadequate, assess compliance and consider:
    • increasing to a dose of sumatriptan to 100mg (if not used already)
    • prescribing second line triptan (almotriptan)
    • subcutaneous sumatriptan should be considered in severe migraine or where vomiting precludes oral treatment or where oral triptans have been ineffective
  • Sumatriptan 50mg tablets are available over-the-counter to buy from pharmacies and patients should be asked about any OTC triptan use.
  • Overuse of triptans (use on more than 2 days per week) should be discouraged due to the risk of medication overuse headache.

Caution

  • Triptans should not be given to people with uncontrolled hypertension, coronary heart disease, cerebrovascular disease or coronary vasospasm.