Acute migraine attack (adult)
Adult 18 years or over with a headache like their usual migraine. Screen for red flags (next step) before any treatment.
All Pathways
NeurologyManagement
Acute Migraine Management
Acute Migraine Management: Acute migraine attack (adult) → Any red flag for a secondary headache? → Red flag present: urgent assessment, not migraine tr...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Decision Any red flag for a secondary headache?
Yes if any: thunderclap onset, fever or neck stiffness, new deficit or atypical aura, new headache at 50 or over, pregnant or postpartum, immunosuppression or cancer, head injury or anticoagulant, attack over 72 h, or a change from the usual pattern. Yes: urgent assessment first.
- Sudden severe onset, peak within 5 minutes (thunderclap)
- Fever, neck stiffness or rash; immunosuppression (HIV, immunosuppressive drugs)
- New neurological deficit, confusion, personality change, reduced consciousness or papilloedema
- Atypical aura: motor weakness, double vision, visual loss in one eye, poor balance
- New headache at age 50 or over, or jaw claudication, scalp tenderness or visual symptoms (giant cell arteritis)
- Pregnant or postpartum; cancer that can spread to the brain
- Triggered by cough, sneeze, Valsalva or exercise; or changes with posture
- Head injury in the past 3 months; new or different headache on an anticoagulant
- Painful red eye with halos (acute angle-closure glaucoma)
- Marked change in pattern, progressive headache, or a new headache with vomiting that has no other cause
- Attack over 72 hours (status migrainosus) or not like previous attacks
- If Yes
03Action Red flag present: urgent assessment, not migraine treatment
Emergency department. Suspected meningitis or giant cell arteritis: treat first, do not wait for CT or LP.
- Thunderclap onset, seizure, collapse or new deficit: non-contrast CT brain now; if CT is normal and subarachnoid haemorrhage is still suspected, LP or CT angiography (see thunderclap headache pathway)
- Suspected bacterial meningitis: give the antibiotic without waiting for CT or LP
- Suspected giant cell arteritis: ESR and CRP, start glucocorticoid the same day, same-day specialist referral
- Pregnant or postpartum: check BP and urine protein (pre-eclampsia); consider venous sinus thrombosis and RCVS
- Head injury or anticoagulant: urgent CT brain
- Suspected venous sinus thrombosis, tumour, IIH or pituitary apoplexy: urgent MRI with MR venography, or CT
04Outcome Red flag: manage the cause
Use the migraine steps only when serious causes are excluded and the headache is the usual migraine.
If No05Warning Before treatment: pregnancy, age under 18, overuse
These change the drug choice.
- Pregnant: paracetamol first. Triptan or NSAID only after discussing risks; no NSAID from 20 weeks. Avoid rimegepant. No valproate or topiramate
- Under 18: the doses in this pathway are for adults. Use paediatric guidance
- Triptans or combination analgesics on 10 or more days a month, or simple analgesics on 15 or more: suspect medication overuse headache
06Warning Before acute drugs: contraindications
If any apply, do not use that drug; choose another. Cardiovascular risk factors (for example diabetes, smoking, hypertension, high cholesterol, man over 40): exclude coronary disease before a first triptan. Over 65: sumatriptan not recommended. SSRI or SNRI: watch for serotonin syndrome. Antiemetics: avoid in Parkinson's disease; metoclopramide not with epilepsy or GI bleeding or obstruction.
- Triptan: not with ischaemic heart disease, prior MI, coronary vasospasm, stroke or TIA, peripheral vascular disease, uncontrolled hypertension, or hemiplegic or brainstem aura
- Triptan: not with an ergot in the past 24 h, severe liver impairment, or (sumatriptan, rizatriptan) an MAOI in the past 2 weeks. On propranolol: not rizatriptan 10 mg. Strong CYP3A4 inhibitor (for example clarithromycin, ritonavir): no eletriptan or rimegepant
- NSAID: not with aspirin- or NSAID-induced asthma, peptic ulcer or GI bleeding, severe kidney disease, heart failure, an anticoagulant, or pregnancy from 20 weeks
07Decision Vomiting, unable to take tablets, or needs ED treatment?
No: oral treatment. Yes: parenteral treatment in the emergency department. Outside ED, if oral drugs are not tolerated: sumatriptan nasal spray or 6 mg SC, or prochlorperazine 12.5 mg IM, before ED referral.
- If Yes
08Action Vomiting or severe: parenteral treatment in ED
Adult doses. Give one antiemetic, not both. Parkinson's disease: avoid both. Do not give opioids.
- Metoclopramide 10 mg IV slowly over 1-2 min, or IM (max 30 mg/day). Age 18-19: prefer prochlorperazine; metoclopramide 5-10 mg as second line only. Not with epilepsy, GI bleeding or obstruction, or phaeochromocytoma
- Or prochlorperazine 12.5 mg deep IM
- Watch for akathisia and acute dystonia
- Sumatriptan 6 mg SC if no triptan was taken for this attack and no triptan contraindication (max 12 mg/24 h)
- Ketorolac 10-30 mg IM only if no NSAID or aspirin taken for this attack, no asthma, not dehydrated, not pregnant, creatinine not over 180 micromol/L (65 and over, under 50 kg or mild kidney impairment: 10-15 mg)
- IV fluids if dehydrated
- Dexamethasone 10 mg IV once to reduce recurrence within 72 h (diabetes: check blood glucose)
09Decision Headache settled after ED treatment?
Yes: discharge with a plan. No: reassess for a secondary cause.
- If Yes
10Action Better: plan the next attack and follow up
Next attack: treat early with what worked. Before ED discharge: return if the headache changes, or with new neurological symptoms or fever.
- Keep triptans and combination analgesics under 10 days a month, simple analgesics under 15 days a month
- Headache diary for at least 8 weeks if frequency or diagnosis is unclear
- Frequent or disabling attacks despite acute treatment: discuss prevention
11Warning If prevention is considered: check pregnancy and contraception first
Pregnant or planning pregnancy: seek specialist advice before any preventive.
- Topiramate: contraindicated for migraine in pregnancy and in women who could become pregnant without highly effective contraception
- Valproate: do not use in women or girls who could become pregnant (not TGA-approved for migraine)
- Propranolol and amitriptyline are dangerous in overdose: ask about depression and self-harm
12Action Prevention: choose by comorbidity
Propranolol: not with asthma, bradycardia, heart block or heart failure. Doses: see Therapeutic Guidelines or product information.
- Propranolol, topiramate or amitriptyline (amitriptyline off-label in Australia)
- Other options: candesartan (off-label), pizotifen
- CGRP antibodies or gepants: specialist or funded criteria (PBS in Australia)
13Outcome Attack treated: follow-up plan in place
GP review of attack frequency, acute drug use and prevention.
If No14Action Not settled, or over 72 hours (status migrainosus): reassess
Recheck for a secondary cause before more treatment. Do not give opioids.
- Recheck red flags; consider venous sinus thrombosis, RCVS, IIH, pituitary apoplexy and medication overuse; image if any is suspected
- Give any first-line drug not yet given (antiemetic, SC sumatriptan, NSAID, dexamethasone), within the maximum doses
- Admit, and seek neurology advice for further treatment
- Do not give an ergot within 24 h of a triptan
15Outcome Refractory attack: admit under specialist care
Neurology-guided treatment after secondary causes are excluded.
If No16Action No vomiting: oral treatment, chosen by severity
Adult doses. Treat early in the attack. Add an antiemetic, even without nausea. Do not use opioids.
- Mild to moderate: aspirin 900 mg, paracetamol 1 g (max 4 g/day), ibuprofen 400 mg, or naproxen 750 mg (then 250-500 mg after 1 h if needed; max 1250 mg/day)
- Moderate to severe, or a simple analgesic did not work before: triptan plus NSAID or paracetamol
- Sumatriptan 50-100 mg orally (max 300 mg/24 h) or 20 mg nasal spray (max 40 mg/24 h); rizatriptan 10 mg (max 30 mg/24 h); eletriptan 40 mg (max 160 mg/24 h)
- Antiemetic: metoclopramide 10 mg orally (age 20 and over; max 30 mg/day) or prochlorperazine 10 mg orally
- Two or more triptans failed, or triptans contraindicated: rimegepant 75 mg orally disintegrating tablet (max 75 mg/24 h)
- Headache comes back after relief: repeat the triptan after at least 2 h, within the daily maximum
17Decision Pain free or much better at 2 hours?
Yes: plan for the next attack. No: escalate.
- If Yes
- Path rejoins step 10Shared downstream outcome
If No18Action Not better at 2 hours: escalate
Recheck red flags if the attack is unusual. Do not use opioids.
- No response to a triptan: do not repeat the same triptan for this attack
- Took a triptan alone or an NSAID alone: add the other (or paracetamol), within daily limits
- Still severe or vomiting: parenteral treatment in ED (see ED step)
- Next attacks: try another triptan or route; after 2 or more triptans fail: rimegepant
- Path rejoins step 08Shared downstream outcome
- Path rejoins step 10Shared downstream outcome
Guideline Source
NICE CG150 Headaches in over 12s: diagnosis and management (last updated June 2025)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only; pregnancy needs obstetric or specialist advice beyond the first-line cautions given.
- Prevention and medication overuse headache are outlined only; see a prevention pathway and Therapeutic Guidelines: Neurology.
- Drug choices and doses follow Australian product information; availability differs by country (for example no dihydroergotamine, lasmiditan or ubrogepant in Australia).
- The red-flag screen supports, and does not replace, clinical judgement and local imaging pathways.
Contraindicated Populations
Children and adolescents under 18 yearsAny red flag for a secondary headache (use the red-flag or thunderclap pathway)
Applicable Regions
AUUKUSEUglobal
AU: Therapeutic Guidelines: Neurology is the local reference. On the ARTG: sumatriptan tablets, nasal spray and 6 mg injection; rizatriptan; eletriptan; rimegepant 75 mg ODT; prochlorperazine 12.5 mg/1 mL injection (IM route in the PI); ketorolac injection (IM route in the PI). Not on the ARTG: dihydroergotamine, lasmiditan, ubrogepant. PBS criteria apply to CGRP-targeting drugs.
UK: NICE CG150 (updated 2025); NICE TA919 (rimegepant) and TA1172 (atogepant) set gepant criteria.
US: AHS 2021 consensus statement (Ailani, doi 10.1111/head.14153), AHS 2016 ED parenteral therapy assessment (Orr, doi 10.1111/head.12835) and ACP 2025 outpatient guideline. Lasmiditan, ubrogepant and dihydroergotamine are available in the US but are not covered here.
Version 2Next review: 2027-09-30
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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 NICE CG150 Headaches in over 12s: diagnosis and management (last updated June 2025).
What guideline is the Acute Migraine Management based on?
This algorithm is based on NICE CG150 Headaches in over 12s: diagnosis and management (last updated June 2025).
What are the limitations of the Acute Migraine Management?
Known limitations include: Adults only; pregnancy needs obstetric or specialist advice beyond the first-line cautions given.; Prevention and medication overuse headache are outlined only; see a prevention pathway and Therapeutic Guidelines: Neurology.; Drug choices and doses follow Australian product information; availability differs by country (for example no dihydroergotamine, lasmiditan or ubrogepant in Australia).; The red-flag screen supports, and does not replace, clinical judgement and local imaging pathways.. Individual patient factors may require deviation from these recommendations.
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