Management of acute treatment of migraine

• acute migraine interventions should be taken early in an attack when gastric absorption is least impaired by migraine-associated gastric stasis (1, 2)
• first-line options include combination therapy or monotherapy with analgesics and triptans; non-oral preparations, anti-emetics, or small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists (gepants) may be used where first-line options are ineffective, contraindicated, or not tolerated (1)
• opioids and ergot alkaloids should not be offered for acute migraine management owing to lack of efficacy and high risk of medication overuse headache (1, 2)

First-Line Acute Pharmacotherapy (NICE Guidance)

Combination Therapy and Monotherapy

• combination therapy: offer an oral triptan combined with a non-steroidal anti-inflammatory drug (NSAID), or an oral triptan combined with paracetamol, taking into account patient preference, comorbidities, and adverse event profiles
• monotherapy: for patients preferring single-agent therapy, consider monotherapy with an oral triptan, an NSAID, aspirin (900 mg), or paracetamol
• aspirin restriction: due to the risk of Reye's syndrome, aspirin-containing preparations must not be offered to individuals aged under 16 years
• young people (aged 12 to 17 years): consider a nasal triptan in preference to an oral triptan

Anti-Emetic Co-Therapy

• routine co-prescription: consider adding an anti-emetic to acute migraine therapy even in the absence of nausea or vomiting
• prokinetic benefit: anti-emetics such as metoclopramide or domperidone relieve nausea and enhance the absorption and efficacy of simultaneously administered oral analgesics (3)

Non-Oral and Second-Line Options

Severe Attack or Oral Intolerance

• for patients in whom oral preparations (or nasal triptans in young people aged 12 to 17 years) are ineffective or not tolerated:
  • consider a non-oral preparation of metoclopramide or prochlorperazine
  • if non-oral metoclopramide or prochlorperazine is selected, consider adding a non-oral NSAID or triptan if not previously tried
  • review special warnings and precautions in product characteristics before prescribing non-oral anti-emetics

Small-Molecule CGRP Antagonists (Gepants)

• rimegepant (oral lyophilisate / sublingual tablet): recommended by NICE as an acute treatment option for migraine with or without aura in adults only if:
  • at least 2 triptans were tried and did not work well enough; or
  • triptans were contraindicated or not tolerated, and NSAIDs and paracetamol were tried but failed to provide adequate relief

Prescribing Precautions and Contraindications

Triptans (5-HT1B/1D Receptor Agonists)

• contraindications:
  • triptans cause vasoconstriction via serotonin receptor pathways and are strictly contraindicated in known or suspected vasospastic or ischaemic vascular disorders (e.g., coronary artery disease, previous stroke/TIA, peripheral arterial disease) and uncontrolled hypertension (4)
• adverse effects:
  • transient limb heaviness, flushing, paraesthesia, and chest/neck/throat tightness; these are usually benign and can be managed by dose reduction, switching to an alternative triptan, or earlier administration (4)

Avoidance of Opioids and Codeine

• codeine and dihydrocodeine:
  • provide minimal additional analgesic benefit in acute headache, increase adverse effects, and are frequently implicated in medication overuse headache
• do not offer ergots or opioids for acute migraine management under any circumstances

Reference:

1. National Institute for Health and Care Excellence (NICE). Headaches in over 12s: diagnosis and management. NICE Clinical Guideline [CG150]. Updated June 2025.
2. British Association for the Study of Headache (BASH). BASH National Management Guidelines for Headache Disorders. 2004.
3. Drug and Therapeutics Bulletin. Acute treatment of migraine. DTB. 1998;36(6):41-4.
4. Zhang N, Robbins MS. Migraine. Annals of Internal Medicine. 2023;176(1):ITC1-ITC16. DOI: 10.7326/AITC202301170.