Acute Migraine Management

Algorithm Steps

1. ▶

   Start

   Acute Migraine Attack

   Patient presenting with migraine

   1. ◆

      Decision

      Assess Attack Severity

      Mild, moderate, or severe?

      • Mild: can function normally
      • Moderate: impaired function
      • Severe: incapacitating, ED presentation
      1. ●

         Action

         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
         1. ◆

            Decision

            Response at 2 Hours?

            Pain-free or adequate relief?

            1. ●

               Action

               Adequate Response

               Continue current regimen

               • Rest in dark, quiet room
               • Hydration
               • Consider prevention if frequent
               • Limit acute med use (<10 days/month)
               1. ●

                  Action

                  Discuss Prevention

                  If ≥4 attacks/month

                  • Beta-blockers, topiramate, valproate
                  • CGRP monoclonal antibodies
                  • Lifestyle modifications
                  • Avoid medication overuse
                  1. ✓

                     Outcome

                     Attack Resolved

                     Follow-up and prevention plan

            2. ●

               Action

               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
               1. ●

                  Action

                  Status Migrainosus / ED

                  >72h or refractory

                  • IV fluids
                  • IV metoclopramide or prochlorperazine
                  • IV ketorolac 30mg
                  • IV dexamethasone 10mg (reduces recurrence)
                  • Consider IV DHE protocol
               2. ●

                  Action

                  CGRP Antagonists (Gepants)

                  Alternative to triptans

                  • Ubrogepant 50-100mg
                  • Rimegepant 75mg ODT
                  • No vasoconstriction
                  • Safe in cardiovascular disease
      2. ●

         Action

         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
         1. ●

            Action

            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
            1. ⚠

               Warning

               ⚠️ Triptan Contraindications

               Avoid in vascular disease

               • CAD, prior MI, stroke
               • Uncontrolled hypertension
               • Hemiplegic or basilar migraine
               • Use gepant or ditan instead
            2. ●

               Action

               Add Antiemetic if Needed

               For nausea/vomiting

               • Metoclopramide 10mg (prokinetic)
               • Prochlorperazine 10mg
               • Ondansetron 4-8mg
               • Enhances analgesic absorption