Acute treatment of migraine headache

Opinion statement

Migraine is a common, chronic neurologic disorder that affects approximately 12% of the adult population in Western countries. Once migraine is diagnosed, illness severity must be assessed. Clinicians and patients should then work together to develop a treatment plan based on patient needs and preferences. The goals of treatment usually include reducing the intensity and duration of acute attacks, minimizing the frequency of attacks, minimizing headache-related disability and maximizing health-related quality of life, and avoiding headache escalation and medication misuse. Management of migraine is divided into pharmacologic and nonpharmacologic approaches. Pharmacologic approaches are subdivided into preventive treatment, taken on a daily basis whether or not headache is present, and acute drugs taken to treat individual attacks as they arise. Acute treatments are further divided into nonspecific agents, which work for all types of pain, and migraine-specific treatments. The US Headache Consortium Guidelines recommend stratified care based on the level of disability to help physicians individualize treatment. Using this approach means that simple analgesics are appropriate as first-line acute treatments for less-disabled patients; if simple analgesics are unsuccessful, treatment is escalated for high-end therapies (eg, triptans). For those with high disability levels, migraine-specific acute therapies, such as the triptans, are recommended as the initial treatment, with preventive drugs in selected patients. A variety of behavioral interventions are helpful. The clinician has an armamentarium of ever-expanding variety of medications. With experience, clinicians can match individual patient needs with the specific characteristics of a drug to optimize therapeutic benefit.