Selecting an Acute Treatment for a Migraine Patient

How to decide which acute treatment is right for your patient

Acute treatments can provide patients with the relief they seek from migraine and headache pain. But how do providers know which acute treatment is right for each patient? Here are the steps to selecting an acute treatment for migraine patients.

Steps to Selecting an Acute Medication for Migraine Patients

Step 1: Conduct a history of present illness

To conduct a history of present illness (HPI), determine the patient’s headache frequency by asking how often they experience moderate to severe headache, what symptoms are associated with their headache, and if their headaches are rapid or gradual in onset. Follow up with questions on how they currently treat headache pain. Do they feel complete relief? How often do they take it? Can they tolerate oral medication during a headache? Finally, inquire about what medications they have taken in the past that have or have not worked.

Step 2: Determine any comorbid conditions or contraindications

Consider any comorbid conditions or concurrent medications that may contraindicate an acute migraine medication before selecting a treatment. For example, patients with a history of stomach ulcers may not be good candidates for oral NSAIDs (nonsteroidal anti-inflammatory drugs). Patients with a history of cardiovascular disease or uncontrolled hypertension may also not be good candidates for triptans. Ask about pregnancy and lactation status, as they can impact safe or approved use of a medication.

Step 3: Review available medication options and make a treatment action plan

After a full history has been taken and comorbidities and contraindications considered, review the available acute treatments and create an action plan. The five categories of acute medications for migraine are NSAIDs, triptans, CGRP antagonists (gepants), ditans and antiemetics. Treatment action plans should be individualized but follow similar guidelines:

• Any patients with severe headache less than eight days a month may only require triptans, gepants or ditans.
• Patients with a mix of severe and moderate headache more than eight days a month may require a combination of triptans, CGRP monoclonal antibodies and ditans for severe pain and NSAIDs for moderate headaches.
• Patients with significant nausea as a symptom may require non-oral treatment or the addition of an antiemetic.

Step 4: Clarify medication limits

Medication limits exist for safety and to prevent acute medication overuse. Medication overuse headache (MOH), also known as rebound headache, is highly prevalent among patients with migraine. Patients could be unknowingly worsening their symptoms by exceeding medication limits.

Primary care practitioners are essential to identifying and treating headache disorders. The American Headache Society’s First Contact – Headache in Primary Care program provides educational resources to empower healthcare professionals and improve headache and migraine care. Learn more about the program here.