Table 1.

Evidence summary for treatment of acute attacks of migraine

DrugQuality of evidence*Scientific effect*Clinical impression of effect*Adverse effectsRole (by consensus)
* See Appendix 2 for explanations of quality of evidence, scientific effect, and clinical impression of effect.
? = not known; NSAIDs = nonsteroidal anti-inflammatory drugs; ASA = acetylsalicylic acid.
Triptans (serotonin1B/1D receptor agonists)
Sumatriptan nasal sprayA++++++OccasionalModerate-to-severe migraine. Useful when nonoral route needed. Less severe migraine when nonopiate medications fail.
Oral triptansModerate-to-severe migraine. Less severe migraine when nonopiate medications fail.
NaratriptanA++++Infrequent
RizatriptanA++++++Occasional
SumatriptanA++++++Occasional
ZolmitriptanA++++++Occasional
Sumatriptan SCA++++++FrequentModerate-to-severe migraine. Useful when nonoral route needed. Less severe migraine when nonopiate medications fail.
Ergot alkaloids and derivatives
DHE IVB+++++FrequentLow recurrence.
DHE SC/IMB+++/+++++OccasionalModerate-to-severe migraine. Less severe migraine when nonopiate medications fail.
DHE IV plus antiemeticsB++++++FrequentStatus migrainosus. Therapy of choice in emergency department.
DHE nasal sprayA++++OccasionalModerate-to-severe migraine. Less severe migraine when nonopiate medications fail.
Low recurrence.
ErgotamineB+++FrequentConsider for selected patients with moderate-to-severe migraine.
Ergotamine plus caffeine
Antiemetics
Chlorpromazine IM/IVC/B++++Mild to moderateAdjunct therapy. May be choice for acute therapy.
Metoclopramide IMB++Infrequent to occasionalAdjunct therapy. May be choice for acute therapy.
PR/IVB++?/++
Prochlorperazine PR/IMB++++/++OccasionalIM/IV adjunct first-line therapy in emergency department or office; consider PR as adjunct.
IVB++++++Frequent
NSAIDs and nonopiate analgesics
AcetaminophenB0+InfrequentPregnant migraineur.
Ketorolac IMB+++InfrequentConsider in emergency department.
Oral NSAIDSOccasionalFirst-line for mild-to-moderate migraine.
AspirinA++++
Diclofenac KB++++
FlurbiprofenB+++
IbuprofenA++++
NaproxenB+++
Naproxen sodiumA++++
Combination analgesics
Acetaminophen, aspirin, caffeineA+++++InfrequentFirst-line for migraine.
Barbiturate hypnotics
Butalbital, ASA, caffeineC?+++OccasionalOccasional use for moderate-to-severe migraine. Limit use due to risk of overuse.
Butalbital, ASA, caffeine, codeineB+++++
Opiate analgesics
Butorphanol nasal sprayA++++++FrequentModerate to severe migraine; rescue therapy.
Limit use.
Opiates—oral combinationsA++++OccasionalModerate to severe migraine; rescue therapy.
Acetaminophen, codeine combinationsLimit use.
Opiates—parenteralB++++FrequentReserved for emergency department use or rescue medication.
Butorphanol IMLimit use.
Meperidine IM/IV
Methadone IM
Other medications
CorticosteroidsC+++InfrequentRescue therapy in status migrainosus.
IV plus antiemetics
Dexamethasone
Hydrocortisone
Isometheptene compoundB+++InfrequentMild-to-moderate headache.
Lidocaine INB++?FrequentUncertain.