Acute migraine pharmaceutical treatment cheat sheet

August 13, 2023 Cerebral Torque

This post is for educational purposes only and may contain errors. Please talk to your neurologist.

Acute migraine pharmaceutical treatment cheat sheet:

Acetaminophen

This is Tylenol.
1000 mg PO recommended.
May be combined with metoclopramide 10 mg PO.
Repeat dose q 4-6 hrs as needed.
The maximum dose is 4 g (4000 mg) daily. but stick with 3 g if you’re a healthy adult to reduce risk of hepatic injury.
Many pain relief products contain acetaminophen so please be careful when taking other medications.
Less effective than NSAIDs.
Considered a safe treatment during pregnancy and breastfeeding.

NSAIDs

See different types and dosage scheduling here:

Different types of NSAIDs and dosage scheduling for migraine

Naproxen has the longest half life of 14 hours so if the headache is prolonged, this is the drug of choice among NSAIDs. It is also the drug of choice for migraineurs who have CVD.
Ibuprofen has decreased GI adverse effects compared to aspirin.
Always avoid aspirin if pregnant and consult with your neurologist about other NSAID possibilities during pregnancy.
Ketorolac (the active ingredient in Toradol) can also be found in nasal spray form called SPRIX.
There are no head to head efficacy trials of NSAIDs, but like triptans, if one is ineffective, another may be tried.

Caffeine

(Can be combined with an NSAID and/or acetaminophen to improve pain [Excedrin]. Better than ibuprofen alone.)

Triptans

Table:

Triptans

Considered first-line for many migraineurs.
May be used with antiemetics and NSAIDs for greater efficacy. Main study done with sumatriptan and naproxen (https://pubmed.ncbi.nlm.nih.gov/18606965/), but it is possible that it may be applied to other combinations.
Better outcome if used early in migraine attack.
If no or inadequate response to one triptan, another may be tried. (https://pubmed.ncbi.nlm.nih.gov/16426262/)
- As the footnote on the table says, do not use triptans within 24 hours of using another triptan or ergot due to additive vasoconstriction.
American Headache society says to NOT worry about using triptans with SSRIs or SNRIs due to the risk of serotonin syndrome. (https://pubmed.ncbi.nlm.nih.gov/20618823/).
Triptans may result in paresthesia-like symptoms in 1-7% of people, but are transient in nature.
Triptans should be limited due to medication overuse headache (MOH), but read my Reddit comment here:

Reddit comment

Antiemetics

Metoclopramide 10-20 mg IV, IM, prochlorperazine 10 mg IV
Generally, only given in the emergency department.
They are dopamine receptor antagonists.
May be given with diphenhydramine 12.5-25 mg q 1-2 hrs to prevent the extrapyramidal effects of this class of medication.
They have antiemetic properties (obviously), but also reduce pain when given IV. (https://pubmed.ncbi.nlm.nih.gov/27300483/)
Other antiemetics are available: chlorpromazine up to 25 mg IV, droperidol 2.5-8.25 mg IM, haloperidol 5 mg IV, and ondansetron IV are also available, but should be used with caution due to QT prolongation.
Oral antiemetics are not recommended monotherapy for acute migraine.

Ergots

Dihydroergotamine
- nasal spray: 0.5 mg (1 spray) into each nostril; repeat once after 15-30 minutes; maximum 4 mg/day
- self-injection (subq or IM): 0.5-1 mg; repeat after 1 hour if needed; maximum 3 mg/day
Only consider when no response to triptans or triptan/NSAID
Do not use with triptan due to additive vasoconstriction
May be combined with antiemetic
Causes medication overuse headache. (https://www.cerebraltorque.com/blogs/migrainescience/medication-overuse-headache-moh-treatment-has-changed-mots-medication-overuse-treatment-strategy-trial)
Ergotamine is not recommended.
American Headache society has no recommendation on Ergots.

Corticosteroids

Dexamethasone IV 10-24 mg IV reduces risk of RECURRENCE. Does not abort migraine. (https://pubmed.ncbi.nlm.nih.gov/18541610/)
For status migrainosus, dexamethasone 10 mg IV may be useful (https://pubmed.ncbi.nlm.nih.gov/17942818/).
For refractory acute migraine, short course of prednisone or dexamethasone used once monthly, at most, may be useful. Dosage is prednisone 50 or 60 mg PO with tapering over 2-3 days, and dexamethasone 8 mg PO with tapering over 2-3 days.

Sodium Valproate

Lasmiditan

5HT-1F receptor agonist
(Reyvow) FDA approved for acute treatment of migraine with or without aura in adults
- 50 mg, 100 mg, or 200 mg PO as needed for migraine
- Do not exceed one dose in 24 hours. No benefit!
May be use if triptans are contraindicated due to cardiovascular risk factors.
May cause CNS depression. Do not drive or operate heavy machinery ≤ 8 hours after taking.
Possible serotonin syndrome. Discontinue medication if any symptoms.

CGRP Antagonists

Long-term safety unknown.
No risk of medication overuse headache.
Rimegepant (Nurtec ODT) FDA approved for acute treatment of migraine in adults with or without aura.
- 75 mg PO on the tongue or sublingually PRN.
- Do not exceed 75 mg (1 tablet) in 24 hours.
Ubrogepant (Ubrelvy) FDA approved for treatment of acute migraine attacks with or without aura in adults.
- 50 mg or 100 mg PO PRN. May give second dose after ≥ 2 hours if required.
- Do not exceed 200 mg in 24 hours.
- Restrictions for renal or hepatic impairment. Talk to your neurologist.
Zavegepant (Zavzpret) FDA approved for treatment of acute migraine attacks with or without aura in adults.

Ginger

250 mg in a 10:1 extract (available on www.cerebraltorque.com)
As efficacious as sumatriptan for the ablative treatment of acute migraine (https://onlinelibrary.wiley.com/doi/10.1002/ptr.4996).
Anti-inflammatory, antioxidant, and reduces CGRP (https://pubmed.ncbi.nlm.nih.gov/27376323/).

Opioids and Butalbital