Migraine is present in 12% of the population and is moderate or severe headache which is frequently disabling. Treatment needs to be given quickly at the onset to work the best.

The following is a list of Acute Therapy Options—to be taken when the Migraine starts, listing from simple to more complex and effective.

• Aspirin (5 grains) with caffeine (60 mg) (Excedrin, Vanquish) 2-3 at onset, then repeat every hour X 2. Limit to 2 treatment days a week. Rebound potential.

• Tylenol (acetaminophen) or an NSAID (non-steroidal anti-inflammatory drug), such as Aleve (naproxen) or Advil (ibuprofen. The dose is 1-2 at onset and repeating once in 2 hours if no improvement. Limit 2 days a week. Rebound potential.

• Cafergot (100mg caffeine and 1 mg ergotamine) The dose is 1-4 at the onset within the first 30 minutes of headache. Use the lowest dose needed to determine what your dose is and this is usually 2-3 Cafergots per headache.

• Not to be used within 24 hours of taking a triptan. Limit to 2 treatment days a week. Max 12/month. If Cafergot makes you nauseated, pretreat with Reglan 5 mg. Rebound potential.

• Cambia (diclofenac potassium for oral solution) This is a non-steroidal anti-inflammatory (NSAID) drug indicated for acute treatment of migraine attacks with or without aura for persons 18 years of age or older. A single 50 mg dose should be given at onset by mixing a single packet contents with 1-2 ounces (30-60 mm) of water. The most common adverse reactions are nausea and dizziness.

• Migranal Dihydroergotamine (DHE) Nasal spray 4mg/ml. One spray (0.5 mg dihydroergotamine) to each nostril at onset every 15 minutes X2 (this is one dose), Max 4 doses per attack, 6 per day, and 8 per week. The half-life is long 10 hours. No reported Rebound potential. This drug may be used for medication overuse headache.

• Trudhesa Trudhesa is designed to be self-administered. Once assembled, Trudhesa should be primed before initial use by releasing 4 sprays. A patient should use Trudhesa immediately after priming. The recommended dose of Trudhesa is 1.45 mg administered as two metered sprays into the nose (one spray of 0.725 mg into each nostril).

• The dose may be repeated, if needed, a minimum of 1 hour after the first dose. A patient should not use more than 2 doses of Trudhesa within a 24-hour period or 3 doses within a 7-day period.

• Dihydroergotamine (DHE) for Intramuscular injection—1 cc at onset of a migraine, Max 3 mg/day, 6 mg/week, may repeat dose every 1 hour. Has to be drawn up from a bottle like insulin and injected in the muscle. May repeat X 1 after 6 hours. No reported Rebound potential. It requires an injection but it can be very effective. The injection is about 6 times more powerful than the nasal spray. Side effects are leg cramp, elevation of blood pressure.

This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, podcaster, YouTube video producer, and blogger.

Read my Mini Book on Migraine Here.

Nasal Oxygen for cluster patients, and some migraine patients with clusters of short, quick headache.  Oxygen is delivered from a canister through plastic tubing to a mask at a flow rate of 6-10 liters/min.

Acute Therapy of the visual aura part of migraine with aura.  2 sniffs of 1% Isuprel (isoproterenol) mustimeter 10 ml vial at onset of visual aura.

Triptans

General triptan rules—don’t use with a personal or strong family history of coronary artery disease.  Don’t use with uncontrolled hypertension.  Limit the dose in children, the elderly (defined here as over 65 years old.), and patients with basilar artery or complicated migraine (aura symptoms over 40 minutes.)  Don’t mix the triptans or take with ergotamine within 24 hours.

Common triptan side effects--chest tightness or pressure, near fainting, neck/back pain which may be burning, warm or hot, dizziness, or drowsiness.

For a more thorough article on treatment side effects read, “Side effects of Acute Migraine Treatment Drugs,” on my website, www.doctormigraine.com. Please click here to read.

A key feature of good Migraine therapy is to treat each individual headache at onset. To learn more about this, read my article “When to Treat Migraine” on my website, doctordoctormigraine.com. Click here to start reading.

Triptans and SSRIs/SNRIs—the FDA has erroneously reported that there is a rare risk of development of serotonin syndrome in patients who take these drugs.  The risk is estimated to the less than 0.03% of patients and life threatening events are less than 0.002%.

In a recent review none of the migraine experts recommended that Triptans and SSRIs or SNRIs be discontinued unless symptoms arise. See my article on The FDA and the Triptan/SSRI/SNRI warning.

The symptoms of serotonin syndrome are restlessness, hallucination, loss of coordination, tachycardia, changes in blood pressure, fever, nausea, vomiting, or diarrhea.  This risk is likely not real and factitious although the FDA hasn’t yet changed their advice.

Want to more about the triptan/serotonin syndrome story? Then please read my article “Serotonin Syndrome” on my website, doctormigraine.com. Click here to read it.

• Imitrex (sumatriptan) most effective when given via a gun type injector. The medicine comes in a vial with a needle and is loaded into the injector like a bullet. The medicine is then injected subcutaneously by pushing a trigger. This is a very slick, high tech system.

• The dose is 1 injection (6mg) at the onset of a migraine, may be repeated at 1 hour for a total dose of 12 mg/24hrs. An oral pill exists also: 25 mg (for kids) or 50, 100 mg (for adults). The usual dose is 50-100 mg at the onset of headache, may repeat at 2 hours (max 200mg/day).

• An Imitrex nasal spray is also available as 1-10 mg squirt per nostril per migraine. For Imitrex the highest drug levels are obtained with the shot, medium drug levels with the pills, and low drug levels with the nasal spray.

• Some patients find the Imitrex nasal spray tastes bad when it goes down the back of the throat. Imitrex went generic December 2008. Rebound potential. Limit to 2 treatment days/week.

• Sumavel DosePro needle free. This is a transdermal, one time use, application supplying 6 mg of sumatriptan subcutaneously by a pressure jet through the skin. Dose is 1 at onset, may repeat in 1 hour. Rebound potential. Limit to 2 treatment days/week.

• Treximet (sumatriptan 85 mg, naproxen 500mg). May be more effective than Imitrex alone. Rebound potential. Limit to 2 treatment days/week.

Tip regarding subcutaneous injections—YouTube has instructional videos on how to do this on the internet.

• Zomig (Zolmatriptan) should decrease the dose by 50% if taken with Tagamet (Cimetidine). Comes as a 2.5 mg or 5 mg tab to be taken one as needed for migraine, trying the 2.5 mg dose size first and moving up to 5 mg (max 10mg/day). Dose at onset 2.5 or 5 mg, may repeat in 2 hours. Also comes as a dissolvable tablet 2.5, 5 ZMT and as a nasal spray 2.5, 5 mg. Rebound potential. Limit to 2 treatment days/week.

• Maxalt (Rizatriptan) comes as a MLT (melt in your mouth) 10 mg wafer and 5, 10 mg tablets. Both are absorbed in the stomach and the MLT, which some patients consider more convenient, is absorbed slower than regular Maxalt. Should reduce the dose by 50% if taken with Inderal (Propranolol). Dose is 1 at onset, may repeat in 2 hours, or take another dose 2 hours later. Maxalt is the only triptan that can be dosed 3 tablets/day. Max 30 mg/day. Rebound potential. Limit to 2 treatment days/week.

• Axert (Almotriptan) Comes as a 6.25 and 12.5 mg tablet. In controlled clinical trials, single doses of 6.25 mg and 12.5 mg of Axert tablets were effective for the acute treatment of migraines in adults, with the 12.5-mg dose tending to be more effective. Dose is 1 at onset, may repeat in 2 hours. Rebound potential. Limit to 2 treatment days/week.

• Relpax (Eletriptan) Comes as a 20 and 40 mg tablet. The 40 mg tablet seems to work the best. Dose is 1 at onset, may repeat at 2 hours. Contraindicated with Antifungals, Macrolide Antibiotics, and Protease Inhibitors. Rebound potential. Limit to 2 treatment days/week.

• Amerge (Naratriptan)—2.5 mg tablet which is the initial dose. May repeat in 2 hours. Onset is 1-2 hours. Amerge is a specialty niche migraine medication for those whose migraine generator in the brain produces a long, slow onset profile. This drug stays around long enough to outlast this type of migraine. The duration of activity is long—6 hours as opposed to 2-3 hours for most of the other triptans, except Frova. Rebound potential. Limit to 2 treatment days/week.

• Frova (frovatriptan) ---Onset 1-2 hours. Good for migraineurs with long duration headache generators. It has a very long duration (26 hour half-life) and lasts four times longer than any other triptan. Thus, it is the drug of choice for menstrual migraine. Taking birth control pills or Inderal may increase blood levels of Frova. Treat with an initial 2.5 mg dose, may repeat in 2 hours. Rebound potential. Limit to 2 treatment days/week.

     Drug                Onset             Usual dose               Maximum 24 hours       Duration of Activity

     Imitrex

     Sumatriptan    

     Oral tablet      15-30 min        50-100 mg                200 mg                            2.5 hours 

     Treximet         15                     1 tablet                      2 tablets                          same

     Nasal Spray   10 min            5, 20 mg                   40 mg                              same

     Subcu 10 min              3, 4, 6 mg                  12 mg                              same

     Dose Pro         10 min             6 mg                          12 mg                              same  

     Zomig

     Zolmitriptan

     Oral tablet    30 min              2.5, 5 mg                  10 mg                                 3 hours

     Nasal Spray   10 min             2.5, 5 mg                   10 mg                                same

     Maxalt

     rizatriptan    30 min              10 mg                        30 mg                                2-3 hours

     Axert

     Almotriptan  30 min              6.25, 12.5 mg          25 mg                                4 hours

     Relpax

     Eletriptan     30 min              20, 40 mg                80 mg                                4 hours

     Amerge

     naratriptan   1-2 hr                2.5 mg                      5 mg                                    6 hours

     Frova

     Frovatriptan 1-2 hr                2.5 mg                      5 mg                                   26 hours 

Medical Devices

Cefaly is an electronic device that provides acute and preventive treatment for Migraine. Cefaly attaches by an electrode to the forehead and sends pulses to the upper branch of the trigeminal nerve which regulates migraine pain. Cefaly is a medical device which has very few side effects and can help persons with migraine who don’t want to take or who respond poorly to available migraine medications.

GammaCore is effective for patients who have failed traditional oral or injectable medications such as triptans, caffeine, or NSAIDS. GammaCore treatment for migraine avoids medication side effects and limits the possible development of medication overuse headache.

New oral pills.

Ditan Reyvow (lasmiditan) is the first of a new treatment , called a Ditan, for the acute treatment of migraine with or without aura. Dose is 50 and 100 mg.

Gepants Nurtec (Rimegepant) is the first of a new kind of acute and preventive treatment for Migraine. Nurtec (Rimegepant) is given as a fast acting orally disintegrating 75 mg tablet to patients with episodic or chronic migraine. Nurtec dose is 75 mg OTC which means oral dissolving tablet.

Ubrelvy (Ubrogepant) is a calcitonin gene-related peptide, CGRP, receptor antagonist for the acute treatment of migraine with or without aura in adults. Dose is 50 and 100 mg.

Summary

Taking one of the fast acting triptans at onset is the best treatment for most persons with Migraine. Triptans don’t work for 20-30% of persons and there may be triptan contraindications for hypertension, heart or stroke problems. This is where the new drugs-Nurtec, Ubrevly, and Reyvow may be tried.

Prescription triptan medication works better than over the counter drugs.

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All the best.

Follow me at:  www.doctormigraine.com, Pinterest, Amazon books, Podbean, and YouTube.

Britt Talley Daniel MD