Migraine
EBM Guidelines
Feb 18, 2022 • Completely updated
Table of contents
Extract
- Effective drug treatment of a migraine attack should be started when the pain is mild.
- Paracetamol or NSAIDs in sufficient doses are suitable for the treatment of mild migraine attacks.
- In severe attacks, triptans are the primary choice.
- In prolonged and severe attacks, a triptan can be combined with an NSAID, and the combination can be taken again within the next 24 hours.
- The antiemetic metoclopramide should be given in addition to analgesics.
- Prophylactic medication should be started if the frequency or severity of attacks affects the patient’s functional ability.
- As it has been shown that opioids do not improve the results of migraine treatment and involve a risk of drug-induced headache, they should not be used.
Linked evidence summaries
- Neuroimaging appears not to be warranted in adult patients with typical migraine with or without visual aura or tension headache and normal neurological examination. Patients presenting with thunderclap headache appear to benefit from investigations regardless of associated clinical features.B
- Paracetamol 1 000 mg is effective in acute migraine, and the addition of metoclopramide 10 mg gives short-term efficacy equivalent to oral sumatriptan 100 mg. Adverse events with paracetamol do not differ from placebo.A↑↑
- Aspirin is more efficient than placebo and similar to sumatriptan for acute migraine headaches; addition of metoclopramide improves relief of nausea and vomiting. Adverse events were less common than with sumatriptan.A
- Oral diclofenac 50 mg appears to be effective for acute migraine.B
- Naproxen is better than placebo in acute migraine, but the NNT of 11 for pain-free response at 2 hours suggests that is not as good as some other medicines such as ibuprofen or sumatriptan with lower NNT results.A
- Ibuprofen is effective for acute migraine headaches, providing pain relief in about half of sufferers.A
- Triptans are more effective than placebo and well tolerated in the treatment of migraine.A
- Naratriptan is effective for acute migraine attack.A
- Oral sumatriptan is effective for the treatment of an acute attack of migraine. The 50 mg dose has slightly lower efficacy than 100 mg dose, but is associated with fewer adverse events.A
- Subcutaneous sumatriptan appears to be effective as an abortive treatment for acute migraine attacks, but is associated with increased adverse events.B
- Intranasal sumatriptan appears to be effective as an abortive treatment for acute migraine attacks. The 20 mg dose appears to have greater efficacy than 10 mg dose, but is associated with more adverse events.B
- Rectally administered sumatriptan may be effective for acute migraine attacks, but is probably associated with increased adverse events.C
- Zolmitriptan is effective for acute migraine attack.A
- The combination of sumatriptan and naproxen is more effective in acute migraine than either sumatriptan or naproxen alone, but additional benefits over sumatriptan alone are not large. Adverse events are more common with the combination and sumatriptan alone than with placebo or naproxen alone.A
- Candesartan may be effective in migraine prophylaxis, being probably more effective than telmisartan.C
- Topiramate in a 100 mg/day dosage is effective in reducing headache frequency and reasonably well-tolerated in adult patients with episodic migraine.A
- Valproate appears to be effective in reducing headache frequency and is reasonably well tolerated in adult patients with episodic migraine.B
- Gabapentin is not efficacious for the prophylaxis of episodic migraine in adults but adverse events are common. There are no studies on pregabalin in episodic migraine.A
- In chronic migraine, botulinum toxin type A may reduce the number of migraine days per month by 2 days compared with placebo. For episodic migraine, it is uncertain whether or not botulinum toxin is effective.C
- Acupuncture in addition to symptomatic treatment of migraine attacks appears to reduce the frequency of headaches. There appears also to be a small effect over sham. Moreover, acupuncture appears to be at least similarly effective as prophylactic drugs.B
Search terms
Acetaminophen, Adrenergic beta-Antagonists, Amitriptyline, Anti-Inflammatory Agents, Aspirin, Atenolol, Atypical facial pain, Basilar migraine, Chronic paroxysmal hemicrania, Cluster Headache, Ergotamine, Facial Pain, G43*, G44.0, Headache, Hemiplegic migraine, Lithium, Metoclopramide, Migraine, Migraine Disorders, Migraine with aura, Neurology, Ophthalmoplegic migraine, Pain, Prednisone, Pregnancy, Prophylaxis, Propranolol, R51, R51.80, Sotalol, Sumatriptan, Tension-Type Headache, Triptan, Triptans, Verapamil