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Symptomatic Treatment of Migraine: When to Use NSAIDs, Triptans, or Opiates

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Opinion statement

Migraine is a biologic disorder of the brain characterized by a heterogeneous array of symptoms and episodes of disabling headache. By definition, such attacks last between 4 and 72 h without treatment, with the disability arising from a variety of factors including severe pain, gastrointestinal symptoms such as nausea or vomiting, and sensory sensitivities to light, noise, or odor. All these features may be exacerbated by stimulation, motion, or activity, often rendering the patient completely immobile. Although retreat and rest, coupled with local application of ice, may provide some measure of comfort, most of those with migraine hunt for therapeutic solutions. In designing acute headache treatment strategies, it is imperative for clinicians to recognize the variability between individuals in the frequency, intensity, and duration of attacks. Certain patients require more aggressive options. It is also crucial to identify the significant intra-individual variability of migraine; most patients describe an assortment of headaches of different intensities and time to disability. Less intense episodes, which patients often term sinus, tension, or regular headaches, usually represent milder versions of migraine, simplifying both diagnostic and therapeutic approaches. Evidence-based guidelines and clinical experience support the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the management of mild to moderate migraine attacks. Recommend migraine-specific agents (triptans and dihydroergotamine) when the attacks are more severe or have consistently failed to respond to the use of NSAIDs in the past. Encourage those with less frequent episodic migraine to use their acute agents at the earliest signs of headache. Advise those with frequent headache (>10 days per month) to limit acute treatments to only the most disabling episodes in order to avoid the “medication overuse” phenomenon. Consider rescue or back-up therapy. Do not use compounds containing butalbital or opiates (or place extreme limits on them), out of concern for progression to chronic migraine.

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Disclosure

Conflicts of Interest: F. Taylor: Board member, Merck Human Health; Consultant for AGA Medical, Inc., Medtronics, Inc., and Merck Scientific Advisory Committee; Member of Merck Speakers Bureau; Grants for Merck Telcagepant study and study for Allergan, Inc.; Royalties from UpToDate, Inc. for authorship of Tension-type Headache in Adults: Pathophysiology, Clinical Features, and Diagnosis. R. Kaniecki: Speaker’s honoraria from Merck, Zogenix, GlaxoSmithKline.

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Authors and Affiliations

  1. Park Nicollet Headache Center, W505 Meadowbrook Building, 3931 Louisiana Avenue South, Minneapolis, MN, 55426, USA

    Frederick R. Taylor MD

  2. The Headache Center, Department of Neurology, University of Pittsburgh, 120 Lynon Avenue, Suite 300, Pittsburgh, PA, 15213, USA

    Robert G. Kaniecki MD

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  1. Frederick R. Taylor MD
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  2. Robert G. Kaniecki MD
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Correspondence to Frederick R. Taylor MD.

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Taylor, F.R., Kaniecki, R.G. Symptomatic Treatment of Migraine: When to Use NSAIDs, Triptans, or Opiates. Curr Treat Options Neurol 13, 15–27 (2011). https://doi.org/10.1007/s11940-010-0107-4

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