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An episodic migraine can last between four hours to three days and may require the following treatment options.
An episodic migraine can last between four hours to three days. The headache lasts for a few hours, but relief from other symptoms or uneasiness caused during a migraine attack may take up to one to three days.
Sometimes, the headache may go away within one to two hours after resting well. It has been observed that children may get relief from a migraine attack within 15 minutes following good sleep.
Episodic migraine treatment chart
Migraine is a common condition and can cause severe morbidity. Thus, numerous therapeutic options are available to address various symptoms. There is no definitive cure for migraine, but the intensity of the pain and other symptoms can be controlled with medications along with the prevention of further attacks.
Randomized controlled trials and systematic reviews are used to assess the benefits and risks of acute therapies for episodic migraine in adults. The key outcomes were pain-free period, pain relief, long-term pain-free period, and adverse events. Evidence has revealed that taking triptans and nonsteroidal anti-inflammatory medications separately are associated with significantly less pain after two hours.
Every research uses a tool called strength of evidence (SOE) to summarize their review based on the findings. The grading system of SOE on drugs indicates the effectiveness of the drug during a randomized trial.
Various acute migraine treatments available are strongly to alleviate pain and improve function, each with varying levels of evidence.
Triptans
Moderate to high SOE
Nonsteroidal anti-inflammatory medications
Moderate to high SOE
Calcitonin gene-related peptide antagonists
Low to high SOE
Lasmiditan
High SOE
Dihydroergotamine
Moderate to high SOE
Ergotamine plus caffeine
Moderate SOE
Acetaminophen
Moderate SOE
Antiemetics
Low SOE
Butorphanol
Low SOE
Tramadol in combination with acetaminophen
Moderate SOE
Electrical neuromodulation
Moderate SOE
Transcranial magnetic stimulation
Low SOE
External trigeminal nerve stimulation
Low SOE
Noninvasive vagus nerve stimulation
Moderate SOE
Effective treatments of migraine include:
- Triptans
- Acetaminophen
- Nonsteroidal anti-inflammatory medications
- Ergot alkaloids
- Antiemetics
- Combination analgesics
- Transcranial magnetic stimulation (stimulation of neurons in the brain with magnetic fields)
What are the treatment options for episodic migraine?
Other nonpharmacological treatments, where the external electrical stimulus is used to stimulate or modify neuronal activities are approved by the U.S. Food and Drug Administration to treat migraines and other chronic pain in the body.
Treatment for mild to moderate acute episodic migraines
Drugs used as first-line treatments for mild to moderate migraine attacks:
- Acetaminophen
- Nonsteroidal anti-inflammatory medications
- Combination analgesics
They can be helpful and are less expensive than migraine-specific drugs. For attacks that do not respond to analgesics, the combination of nonsteroidal anti-inflammatory drugs and a triptan appears to be more efficacious than either of the medication class alone.
When mild to moderate bouts are accompanied by severe nausea or vomiting, an antiemetic medication can be administered in conjunction with simple or combination analgesics.
Treatment for moderate to severe acute episodic migraines
Oral migraine-specific medications, such as sumatriptan and the sumatriptan-naproxen combination, are the first-line treatment for moderate to severe migraine attacks that are not accompanied by vomiting or severe nausea.
If triptans are contraindicated or not tolerated, a calcitonin gene-related peptide (CGRP) antagonist or lasmiditan may be beneficial.
Severe migraine attacks can be treated with an antiemetic drug or nonoral migraine-specific medications, such as:
- Subcutaneous sumatriptan
- Nasal sumatriptan and zolmitriptan
- Parenteral dihydroergotamine
Treatment for severe intractable migraine attacks or status migrainosus
Status migrainosus is a severe debilitating migraine attack that lasts for more than 72 hours. Status migrainosus is treated with intravenous fluids and parenteral drugs, such as ketorolac and a dopamine receptor blocker.
Depending on the response to initial therapy, more parenteral medicines, such as valproate and dihydroergotamine, may be indicated. Medication selection is modified with patient-specific characteristics. Parenteral dexamethasone is frequently used to prevent the relapse of an episode.
Patients may need to be admitted if they have chronic debilitating symptoms despite the first treatment regimen or if they are being weaned off of medication to monitor for withdrawal symptoms.
Treatment for variable migraine attacks
Many people with migraine experience attack that range in severity, onset timing, and correlation with vomiting and nausea. These patients may require two or more alternatives for acute migraine self-management, including oral drugs for mild to moderate episodes and non-oral treatments, such as subcutaneous or nasal triptans, for severe attacks or other associated symptoms, such as nausea and vomiting.
Treatment for severe migraine attacks in emergency settings
Patients who report migraine in emergency rooms have extremely severe attacks, and, in many situations, standard acute migraine treatment has failed to offer relief. The treatment of migraine attacks in the emergency room is similar to non-urgent settings, with the exception that parenteral medicines are more quickly available.
It is recommended to start treatment with either subcutaneous sumatriptan or a parenteral antiemetic for patients who report to the hospital emergency room with severe migraine, especially if the migraine is accompanied by severe nausea or vomiting.
Treatment for migraine attacks in pregnancy
Because of concerns regarding potential adverse fetal drug effects, migraine treatment in pregnancy differs slightly from that of nonpregnant females. The first-line treatment is acetaminophen, which has the best maternal-fetal safety profile.
If this medicine is ineffective, the next drugs administered as first-line treatment are:
- Combination of acetaminophen and metoclopramide
- Combination of acetaminophen and codeine
- Butalbital-acetaminophen-caffeine
Second-line treatment:
- Aspirin
- Nonsteroidal anti-inflammatory medications
Third-line treatment:
- Opioids
- Triptans
Patients suffering from migraine who have not responded to oral medications after many days should be investigated for aggravating factors and treated more aggressively.
Treatment for medication overuse headache (MOH)
Medication overuse headache also called analgesic rebound headache, is a common disorder with high morbidity. Many symptomatic drugs used to treat headaches can produce MOH. However, the level of risk varies based on the prescription or class of medications.
Based on the clinical experience, opioids, butalbital-containing combination analgesics, and aspirin-acetaminophen-caffeine combinations appear to pose the greatest risk for MOH. Some experts believe triptans to be of intermediate danger, while others consider them to be of high risk.
MOH can be avoided with various calcitonin gene-related peptide (CGRP) antagonists, which are useful for both preventive and acute migraine treatment. To prevent MOH, treatment of frequent headaches should be limited to less than 15 days for aspirin, acetaminophen, and nonsteroidal anti-inflammatory drugs per month.
The pharmacologic qualities, probable side effects, cost, and routes of administration differ greatly, allowing therapy to be personalized to the pattern and severity of attacks. Several therapeutic approaches, such as taking medicine early in an attack and utilizing a stratified treatment approach, can help ensure that migraine therapy is affordable.
