Acute Migraine Treatments - What Works?

Patient Expert
Reviewed by
Teri Robert

The migraine topic about which I see the most questions is whether specific acute migraine medications (the medications we use when we get a migraine) work. The problem with those questions has been that nothing works for all migraineurs, so the answers have been along the lines of, "It works for some people. The only way to know is to try it."

Now, thanks to a study conducted and published by American Headache Society researchers, the evidence from other studies on the efficacy of acute treatments has been gathered and assessed. Their assessment resulted in acute treatments being categorized in a fashion that at least shows which acute treatments have the most evidence of being effective and which may be ineffective.

The Study:

Study Goal:

"The study aims to provide an updated assessment of the evidence for individual pharmacological therapies for acute migraine treatment."1

Background:

"Pharmacological therapy is frequently required for acutely treating migraine attacks. The American Academy of Neurology Guidelines published in 2000 summarized the available evidence relating to the efficacy of acute migraine medications. This review, conducted by the members of the Guidelines Section of the American Headache Society, is an updated assessment of evidence for the migraine acute medications."1

Study Methods:

  • A standardized literature search was performed to identify articles related to
    acute migraine treatment that were published between 1998 and 2013.
  • The American Academy of Neurology Guidelines Development procedures were followed.
  • Two authors reviewed each abstract resulting from the search and determined whether the full manuscript qualified for review.
  • Two reviewers studied each qualifying full manuscript for its level of evidence.
  • Level A evidence requires at least two Class I studies, and Level B evidence requires one Class I or two Class II studies.
  • Following the assessment of the collected data, acute migraine medications were classified as:
    • Level A: Medications are established as effective for acute migraine treatment based on available evidence.
    • Level B: Medications are probably effective for acute migraine treatment based on available evidence/
    • Level C: Medications are possibly effective for acute migraine treatment based on available evidence.
    • Level U: Evidence is conflicting or inadequate to support or refute the efficacy of the following medications for acute migraine.
    • Level B negative: Medication is probably ineffective for acute migraine.
    • Level C negative: Medication is possibly ineffective for acute migraine.

Study Results:

The table below shows where each of the acute treatments was classified. It is page 11 of "The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies," and is republished here with the permission of the authors. My thanks go to Dr. Marmura, Dr. Silberstein, and Dr. Schwedt.

**Level A** (effective) **Level B** (probably effective) **Level C** (possibly effective) **Level U** (evidence confl/inad) **Others**

**Analgesic** Acetaminophen

1000 mg (for

non

incapacitating

attacks

**Antiemetics** *Chlorpromazine IV

12.5 mg
Droperidol IV 2.75 mg
*Metoclopramide IV

10 mg
*Prochlorperazine IV/IM

10 mg; PR 25 mg

**Antiepileptic** Valproate IV 400-1000 mg **NSAIDs** Celecoxib 400 mg **Level B negative Other** Octreotide SC 100
           
**Ergots** DHE *Nasal Spray 2 mg Pulmonary inhaler 1 mg **Ergots** DHE* IV, IM, SC 1mg *Ergotamine/Caffeine 1/100mg **Ergot** *Ergotamine 1-2 mg **Others** *Lidocaine IV *Hydorcortisone

IV 50 mg

**Level C negative

Antiemetics**
*Chlorpromazine

IM 1 mg/kg
*Granisetron IV

40-80 g/kg

           
**NSAIDs** *Aspirin 500 mg Diclofenac 50, 100 mg Ibuprofen 200, 400 mg *Naproxen 500, 550 mg **NSAIDs** *Flurbiprofen 100 mg Ketoprofen 100 mg Ketorolac IV/IM 30-60 mg **NSAIDs** Phenazone 1000 mg   **NSAIDs** Ketorolac tromethamine nasal spray
           
**Opioids** *Butorphanol nasal spray 1 mg   **Opioid** *Butorphanol IM 2 mg *Codeine 30 mg PO *Meperidine IM 75 mg *Methadone IM 10 mg *Tramadol IV 100 mg   **Analgesic** Acetaminophen IV 1000 mg
           
**Triptans** Almotriptan 12.5 mg Eletriptan 20, 40, 80 mg Frovatriptan 2.5 mg *Naratriptan 1, 2.5 mg *Rizatriptan 5, 10 mg Sumatriptan *Oral 25, 50, 100 mg *Nasal spray 10, 20 mg Patch 6.5 mg *SC 4, 6 mg Zolmitriptan nasal spray 2.5, 5 mg *Oral 2.5, 5 mg **Others** MgSO4 IV (migraine with aura) 1-2 g *Isometheptene 65 mg **Steroid** Dexamethasone IV 4-16 mg    
           
**Combinations** *Acetaminophen/aspirin/ caffeine 500/500/130 mg Sumatriptan/naproxen 85/500 mg **Combinations** *Codeine/acetaminophen 25/400 mg Tramadol/acetaminophen 75/650 mg **Others** *Butalbital 50 mg *Lidocaine intranasal    
           
    **Combinations** *Butalbital/acetaminophen/ caffeine/codeine 50/325/ 40/30 mg *Butalbital/acetaminophen/ caffeine 50/325/40 mg    
 
*Based on 2000 American Academy of Neurology evidence review.
Level A: Medications are established as effective for acute migraine treatment based on available evidence.
Level B: Medications are probably effective for acute migraine treatment based on available evidence.
Level C: Medications are possibly effective for acute migraine treatment based on available evidence.
Level U: Evidence is conflicting or inadequate to support or refute the efficacy of the following medications for acute migraine.
Level B negative: Medication is probably ineffective for acute migraine.
Level C negative: Medication is possibly ineffective for acute migraine.

You may download this table in PDF format.

Study Conclusion:

"According to this systematic review of the literature and structured grading of the evidence strength, specific medications within the following classes are considered "effective" for the acute therapy of migraine: triptans, ergotamine derivatives, NSAIDs, opioids, and combination medications. Several other medications are considered "probably effective" or "possibly effective." This evidence base for medication efficacy should be considered along with potential medication side effects, potential adverse events, patient-specific contraindications to use of a particular medication, and drug-to-drug interactions when deciding which medication to prescribe for acute therapy of a migraine attack."1

Summary and Comments:

It's very helpful to have the information from the various studies collected for us so we can look at the chart above to see the aggregation of the evidence from all the studies in one place. That said, even those medications classified as Level B negative and Level C negative are worth a try if other medications haven't worked or are insufficient.

There's a link at the bottom of the table above so you can download a copy of the table in PDF format. Printing it and taking it with you when you go to the doctor who treats you for Migraine would be helpful when you and your doctor are reviewing your treatment options.


Sources:

1 Marmura, Michael J, MD; Silberstein, Stephen D., MD, FACP; Schwedt, Todd J., MD, MSCI. "The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies." Headache 2015;55:3-20.

2 Silberstein, Stephen D., MD; Marmura, Michael J., MD. "Acute Migraine Treatment." Headache 2015; 55: 1-2.

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