Acute Migraine Attack
Patient presenting with migraine
All Pathways
NeurologyManagement
Acute Migraine Management
Acute Migraine Management: Acute Migraine Attack → Assess Attack Severity → Mild-Moderate Attack → Response at 2 Hours? → Adequate Response.
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Decision Assess Attack Severity
Mild, moderate, or severe?
- Mild: can function normally
- Moderate: impaired function
- Severe: incapacitating, ED presentation
03Action Mild-Moderate Attack
Start with simple analgesics
- NSAIDs: ibuprofen 400-800mg, naproxen 500mg
- Acetaminophen 1000mg (if NSAIDs contraindicated)
- Aspirin + caffeine effective
- Treat early for best effect
04Decision Response at 2 Hours?
Pain-free or adequate relief?
05Action Adequate Response
Continue current regimen
- Rest in dark, quiet room
- Hydration
- Consider prevention if frequent
- Limit acute med use (<10 days/month)
06Action Discuss Prevention
If ≥4 attacks/month
- Beta-blockers, topiramate, valproate
- CGRP monoclonal antibodies
- Lifestyle modifications
- Avoid medication overuse
07Outcome Attack Resolved
Follow-up and prevention plan
08Action Inadequate Response
Rescue therapy options
- Repeat triptan at 2h (different route?)
- Add NSAID if not tried
- Gepant (ubrogepant 50-100mg)
- Consider ED if severe/prolonged
09Action Status Migrainosus / ED
>72h or refractory
- IV fluids
- IV metoclopramide or prochlorperazine
- IV ketorolac 30mg
- IV dexamethasone 10mg (reduces recurrence)
- Consider IV DHE protocol
- Path rejoins step 06Shared downstream outcome
10Action CGRP Antagonists (Gepants)
Alternative to triptans
- Ubrogepant 50-100mg
- Rimegepant 75mg ODT
- No vasoconstriction
- Safe in cardiovascular disease
- Path rejoins step 06Shared downstream outcome
11Action Severe Attack
Triptan or other migraine-specific therapy
- Triptans: first-line for moderate-severe
- Consider gepants if triptan contraindicated
- Ditans (lasmiditan) if vascular risk
- Early treatment improves response
12Action Triptan Selection
Choose based on patient factors
- Sumatriptan 50-100mg PO, 6mg SC, nasal
- Rizatriptan 10mg (fast onset)
- Eletriptan 40mg (longer duration)
- Zolmitriptan nasal (non-oral option)
- Can repeat in 2h if partial response
13Warning ⚠️ Triptan Contraindications
Avoid in vascular disease
- CAD, prior MI, stroke
- Uncontrolled hypertension
- Hemiplegic or basilar migraine
- Use gepant or ditan instead
- Path rejoins step 10Shared downstream outcome
14Action Add Antiemetic if Needed
For nausea/vomiting
- Metoclopramide 10mg (prokinetic)
- Prochlorperazine 10mg
- Ondansetron 4-8mg
- Enhances analgesic absorption
- Path rejoins step 04Shared downstream outcome
Guideline Source
AHS Consensus Statement: Update on Acute Migraine Treatment
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not cover preventive therapy in detail
- Medication overuse headache requires different approach
- Pediatric dosing differs
- Pregnancy requires special considerations
Applicable Regions
USEUglobal
EU: EHF guidelines similar
US: AHS 2021 and AAN guidelines
Version 1Next review: 2027-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Acute Migraine Management?
The Acute Migraine Management is a management clinical algorithm for Neurology. It provides a structured decision tree to guide clinical decision-making, based on AHS Consensus Statement: Update on Acute Migraine Treatment.
What guideline is the Acute Migraine Management based on?
This algorithm is based on AHS Consensus Statement: Update on Acute Migraine Treatment (DOI: 10.1111/head.14074).
What are the limitations of the Acute Migraine Management?
Known limitations include: Does not cover preventive therapy in detail; Medication overuse headache requires different approach; Pediatric dosing differs; Pregnancy requires special considerations. Individual patient factors may require deviation from these recommendations.
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