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. |