Fast Five Quiz: Acute Management for Migraine

Medscape

28-05-2025

Migraine is a complex disorder characterized by recurrent episodes of headache often associated with visual or sensory symptoms, collectively known as an aura, that usually arise before the head pain but that might occur during or afterward. Further, migraine has a strong genetic component. Additionally, a variety of environmental and behavioral factors might precipitate migraine attacks in individuals with a predisposition to migraine. Acute management of migraine headache should provide rapid relief from headache pain and related symptoms, restore patient functioning, and prevent recurrence.
What do you know about acute management for migraine? Check your knowledge with this quick quiz.
Acute medications for migraine include triptans, ergotamine derivatives, gepants, and certain serotonin 5-HT1F receptor agonists, although nonspecific drugs such as NSAIDs can be used as well. A recent systematic review and network meta-analysis found that triptans have the best safety profiles and efficacy for treating migraine when compared with other drugs such as certain serotonin 5-HT1F receptor agonists, gepants, and NSAIDs. Featured head-to-head comparisons found that the triptans were the most efficacious for pain freedom at 2 hours. However, the same meta-analysis noted that cost effectiveness and cardiovascular risk should also be considered before use, as 'cerebrovascular events may present primarily as migraine-like headaches, and misdiagnosis of transient ischemic attack and minor stroke as migraine is not rare.'
Learn more about triptans for migraine.
For acute treatment of migraine, the American Headache Society (AHS) recommends administering medical therapy as soon as symptoms appear; more specifically, researchers note that within 30 minutes is preferable, according to a recent review. Other sources suggest utilizing therapy within 15 minutes for those who experience migraine with aura. This time frame is generally more effective for management rather than specifically waiting for aura phase to complete or when pain reaches moderate intensity. However, even if a patient is unable to take medication within that time frame, taking medication during the episode can reduce symptom severity and migraine duration. A recent meta-analysis also explored the difference in efficacy between different acute medications for migraine, which can be found here.
Learn more about acute treatments for migraine.
The AHS encourages the use of validated measures of migraine treatment response to guide management decisions. Specifically, they suggest mTOQ for assessing acute treatment, as well as the Migraine Assessment of Current Therapy (Migraine-ACT), Patient Perception of Migraine Questionnaire (PPMQ-R), Functional Impairment Scale (FIS).
In the same guidelines, the AHS suggests PGIC, MFIQ, or MSQ v2.1 as valid instruments for measuring response to preventative migraine treatment.
Learn more about migraine severity measures.
REN is approved for use by the FDA for both prophylactic and acute treatment of migraine in adults and pediatric patients ages 8 years and older. For migraine prevention and treatment, eTNS and TENS are approved only for adults, and eCOT-NS is approved only for acute treatment in adults with migraine. Of the approved devices, eTNS, REN, and noninvasive vagus nerve stimulation (nVNS) are specifically mentioned by the AHS for use alone or in conjunction with pharmacotherapy, and single-pulse transcranial magnetic stimulation (sTMS) can also be used as monotherapy for preventive treatment. Further, nVNS and sTMS can be used in both patients 12-17 years and adults.
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Before a patient can initiate acute treatment for migraine with gepants, ditans, or neuromodulatory devices, the AHS recommends trialing at least two oral triptans. Treatment failure can be assessed by validated patient-reported outcome questionnaires (mTOQ, Migraine-ACT, PPMQ-R, FIS, PGIC) or clinician attestation. Risk factors for an inadequate response to triptan include severe baseline headache severity, nausea, depression, photophobia, and phonophobia. Further, triptans are contraindicated for patients with vascular diseases.
CGRP inhibitors are usually not recommended as an initial acute treatment for migraine. Though caffeine can be used as an adjuvant to initial analgesics for migraine, it usually does not determine the initiation of gepants, ditans, or neuromodulatory devices. Inadequate response to combination therapy including NSAIDs, a recommended non-pharmacologic regimen, and CGRP inhibitors are not part of the criteria for initiating acute treatment with gepants, ditans, or neuromodulatory devices from the AHS.
Learn more about acute treatments for migraine.