Evidence summary for treatment of acute attacks of migraine
Drug | Quality of evidence* | Scientific effect* | Clinical impression of effect* | Adverse effects | Role (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 spray | A | +++ | +++ | Occasional | Moderate-to-severe migraine. Useful when nonoral route needed. Less severe migraine when nonopiate medications fail. |
Oral triptans | Moderate-to-severe migraine. Less severe migraine when nonopiate medications fail. | ||||
Naratriptan | A | ++ | ++ | Infrequent | |
Rizatriptan | A | +++ | +++ | Occasional | |
Sumatriptan | A | +++ | +++ | Occasional | |
Zolmitriptan | A | +++ | +++ | Occasional | |
Sumatriptan SC | A | +++ | +++ | Frequent | Moderate-to-severe migraine. Useful when nonoral route needed. Less severe migraine when nonopiate medications fail. |
Ergot alkaloids and derivatives | |||||
DHE IV | B | ++ | +++ | Frequent | Low recurrence. |
DHE SC/IM | B | +++/++ | +++ | Occasional | Moderate-to-severe migraine. Less severe migraine when nonopiate medications fail. |
DHE IV plus antiemetics | B | +++ | +++ | Frequent | Status migrainosus. Therapy of choice in emergency department. |
DHE nasal spray | A | ++ | ++ | Occasional | Moderate-to-severe migraine. Less severe migraine when nonopiate medications fail. |
Low recurrence. | |||||
Ergotamine | B | + | ++ | Frequent | Consider for selected patients with moderate-to-severe migraine. |
Ergotamine plus caffeine | |||||
Antiemetics | |||||
Chlorpromazine IM/IV | C/B | ++ | ++ | Mild to moderate | Adjunct therapy. May be choice for acute therapy. |
Metoclopramide IM | B | + | + | Infrequent to occasional | Adjunct therapy. May be choice for acute therapy. |
PR/IV | B | ++ | ?/++ | ||
Prochlorperazine PR/IM | B | +++ | +/++ | Occasional | IM/IV adjunct first-line therapy in emergency department or office; consider PR as adjunct. |
IV | B | +++ | +++ | Frequent | |
NSAIDs and nonopiate analgesics | |||||
Acetaminophen | B | 0 | + | Infrequent | Pregnant migraineur. |
Ketorolac IM | B | + | ++ | Infrequent | Consider in emergency department. |
Oral NSAIDS | Occasional | First-line for mild-to-moderate migraine. | |||
Aspirin | A | ++ | ++ | ||
Diclofenac K | B | ++ | ++ | ||
Flurbiprofen | B | + | ++ | ||
Ibuprofen | A | ++ | ++ | ||
Naproxen | B | + | ++ | ||
Naproxen sodium | A | ++ | ++ | ||
Combination analgesics | |||||
Acetaminophen, aspirin, caffeine | A | +++ | ++ | Infrequent | First-line for migraine. |
Barbiturate hypnotics | |||||
Butalbital, ASA, caffeine | C | ? | +++ | Occasional | Occasional use for moderate-to-severe migraine. Limit use due to risk of overuse. |
Butalbital, ASA, caffeine, codeine | B | ++ | +++ | ||
Opiate analgesics | |||||
Butorphanol nasal spray | A | +++ | +++ | Frequent | Moderate to severe migraine; rescue therapy. |
Limit use. | |||||
Opiates—oral combinations | A | ++ | ++ | Occasional | Moderate to severe migraine; rescue therapy. |
Acetaminophen, codeine combinations | Limit use. | ||||
Opiates—parenteral | B | ++ | ++ | Frequent | Reserved for emergency department use or rescue medication. |
Butorphanol IM | Limit use. | ||||
Meperidine IM/IV | |||||
Methadone IM | |||||
Other medications | |||||
Corticosteroids | C | + | ++ | Infrequent | Rescue therapy in status migrainosus. |
IV plus antiemetics | |||||
Dexamethasone | |||||
Hydrocortisone | |||||
Isometheptene compound | B | + | ++ | Infrequent | Mild-to-moderate headache. |
Lidocaine IN | B | ++ | ? | Frequent | Uncertain. |