Acute Treatments

Efficient and reliable acute treatment aims to restore your ability to resume daily activities within 1 to 2 hours. The medication should be effective, reliable, and have no significant side effects. If you have severe attacks, the goal may be to decrease symptoms (pain, nausea, sensory sensitivity, others) even if a return to function is not possible.

Identifying migraine symptoms such as light sensitivity, irritability, nausea, and throbbing pain can help distinguish migraine attacks from tension headaches. Recognizing these warning signs can aid in early treatment, potentially increasing success rates. Many migraine attacks start at a mild degree but then deteriorate. 

Since each patient responds differently, finding the right acute treatment may involve trying various medications and combinations. It is rare for a treatment to be effective for 100% of attacks, so we suggest that you try each new medication for a few three separate migraine attacks. Tracking responses in a migraine diary and evaluating benefits and side effects can guide treatment decisions in consultation with your healthcare provider. 

Treating the attack early increases your chances of success and return to function. For some people, their migraine attacks are always the same, but others have different types, some rising quickly, others slowly. Some start during sleep. The sequence of symptoms may vary, but once an attack is full blown, it becomes more difficult to stop it.  In the case of gepants, studies have shown that treating during your prodrome (if you have a recognizable and reliable one) can be beneficial.

Consider asking your doctor for a medication that does not need to be absorbed by the stomach, such as a nasal spray, suppository, or injection. Such options may be effective.

The different categories of acute medications may be taken together to treat different parts of the attack. For example, you may need something for pain and nausea. Different migraine medications act through various mechanisms, and combining them may increase your chances of success. Different attacks may require different combinations. 

It is crucial to exercise caution if experiencing headaches more than two days a week. The risk of drug-induced (rebound or medication overuse) headache starts at 10 days per month, and gets higher with higher frequency. If you have headaches more often than this, you may need a preventive medication to help reduce the frequency of your migraine attacks. As a note, gepants taken acutely do not induce rebound, they could even add a preventive effect.

Opioids are usually avoided for migraine treatment because they are more likely to result in a temporary response where the migraine returns in a few hours or the next day. The brain becomes more sensitized to pain following the use of opioids and there is greater risk for rebound headaches. The pattern of migraine often becomes more frequent and more severe in people who use opioids.

References: 

• Worthington I, Pringsheim T, Gawel MJ, Gladstone J, Cooper P, Dilli E, et al. Canadian Headache Society Guideline: acute drug therapy for migraine headache. Can J Neurol Sci. 2013;40(5 Suppl 3):S1-s80.
• Gilmore B, Michael M. Treatment of acute migraine headache. Am Fam Physician. 2011;83(3):271-80.
• Mayans L, Walling A. Acute Migraine Headache: Treatment Strategies. Am Fam Physician. 2018;97(4):243-51.
• Rapoport AM. Acute treatment of migraine: established and emerging therapies. Headache. 2012;52 Suppl 2:60-4.