Canadian Headache Society Guideline: Acute Drug Therapy for Migraine Headache

ABSTRACT:Objectives:The primary objective of this guideline is to assist the practitioner in choosing an appropriate acute medication for an individual with migraine, based on current evidence in the medical literature and expert consensus. It is focused on patients with episodic migraine (headache on < 14 days a month).Methods:A detailed search strategy was used to find relevant meta-analyses, systematic reviews and randomized double-blind controlled trials. Recommendations were graded with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, using a consensus group. In addition, a general literature review and expert consensus were used for aspects of acute therapy for which randomized controlled trials are not available.Results:Twelve acute medications received a strong recommendation for use in acute migraine therapy (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ASA, ibuprofen, naproxen sodium, diclofenac potassium, and acetaminophen). Four received a weak recommendation for use (dihydroergotamine, ergotamine, codeine-containing combination analgesics, and tramadol-containing combination analgesics). Three of these were NOT recommended for routine use (ergotamine, and codeine- and tramadol-containing medications). Strong recommendations were made to avoid use of butorphanol and butalbital-containing medications. Metoclopramide and domperidone were strongly recommended for use where necessary. Our analysis also resulted in the formulation of eight general acute migraine treatment strategies. These were grouped into: 1) two mild-moderate attack strategies, 2) two moderate-severe attack or NSAID failure strategies, 3) three refractory migraine strategies, and 4) a vasoconstrictor unresponsive-contraindicated strategy. Additional strategies were developed for menstrual migraine, migraine during pregnancy, and migraine during lactation.Conclusion:This guideline provides evidence-based advice on acute pharmacological migraine therapy, and should be helpful to both health professionals and patients. The available medications have been organized into a series of strategies based on patient clinical features. These strategies may help practitioners make appropriate acute medication choices for patients with migraine.

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Pharmacological Acute Migraine Treatment Strategies: Choosing the Right Drug for a Specific Patient

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100118979 ◽

2013 ◽

Vol 40 (S3) ◽

pp. S33-S62 ◽

Cited By ~ 2

Author(s):

Irene Worthington ◽

Tamara Pringsheim ◽

Marek J. Gawel ◽

Jonathan Gladstone ◽

Paul Cooper ◽

...

Keyword(s):

Literature Review ◽

Treatment Strategies ◽

Drug Efficacy ◽

Migraine Treatment ◽

Acute Migraine ◽

Review Section ◽

Specific Patient ◽

Medical Disorders ◽

Acute Medication ◽

Acute Migraine Treatment

ABSTRACT:Background:In our targeted review (Section 2), 12 acute medications received a strong recommendation for use in acute migraine therapy while four received a weak recommendation for use. Strong recommendations were made to avoid use of two other medications, except for exceptional circumstances. Two anti-emetics received strong recommendations for use as needed.Objective:To organize the available acute migraine medications into acute migraine treatment strategies in order to assist the practitioner in choosing a specific medication(s) for an individual patient.Methods:Acute migraine treatment strategies were developed based on the targeted literature review used for the development of this guideline (Section 2), and a general literature review. Expert consensus groups were used to refine and validate these strategies.Results:Based on evidence for drug efficacy, drug side effects, migraine severity, and coexistent medical disorders, our analysis resulted in the formulation of eight general acute migraine treatment strategies. These could be grouped into four categories: 1) two mild-moderate attack strategies, 2) two moderate-severe attack or NSAID failure strategies, 3) three refractory migraine strategies, and 4) a vasoconstrictor unresponsive-contraindicated strategy. In addition, strategies were developed for menstrual migraine, migraine during pregnancy, and migraine during lactation. The eight general treatment strategies were coordinated with a “combined acute medication approach” to therapy which used features of both the “stratified” and the “step care across attacks” approaches to acute migraine management.Conclusions:The available medications for acute migraine treatment can be organized into a series of strategies based on patient clinical features. These strategies may help practitioners make appropriate acute medication choices for patients with migraine.

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Rimegepant: acute treatment for migraine headaches

Pain Management ◽

10.2217/pmt-2020-0090 ◽

2021 ◽

Author(s):

Golden L Peters ◽

Erin K Hennessey

Keyword(s):

Migraine Headache ◽

Acute Treatment ◽

Treatment Options ◽

Migraine Treatment ◽

Acute Migraine ◽

The Past ◽

Vasoactive Peptides ◽

Migraine Headaches ◽

Calcitonin Gene ◽

Acute Migraine Treatment

Migraine headache treatment is quickly evolving. There have been three new acute migraine treatment options (i.e., lasmiditan, rimegepant, ubrogepant) and four new preventive migraine treatment options (i.e., erenumab, fremanezumab, galcanezumab, eptinezumab) released in the past 3 years. The new migraine treatments are focusing on pathways within the newly, better understood neurovascular hypothesis that further describes the pathophysiology of migraine headaches in more detail than before. The discovery of vasoactive peptides, such as calcitonin gene-related peptide, has led to the development of many of these migraine agents. Rimegepant is one of these newly approved agents for acute migraine treatment in adults with or without aura. Rimegepant has been found to decrease pain and symptoms associated with migraine attacks and is generally well-tolerated.

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What efficacy measures are clinically relevant and should be used in Cochrane Reviews of acute migraine trials? A viewpoint

Cephalalgia ◽

10.1177/0333102414545347 ◽

2014 ◽

Vol 35 (5) ◽

pp. 457-459 ◽

Cited By ~ 1

Author(s):

Peer Tfelt-Hansen

Keyword(s):

Clinical Relevance ◽

Migraine Headache ◽

Cochrane Review ◽

Migraine Treatment ◽

Acute Migraine ◽

High Quality ◽

Cochrane Reviews ◽

Headache Relief ◽

Efficacy Measures ◽

Acute Migraine Treatment

Background Cochrane Reviews are methodologically of high quality but the clinical relevance of analysed efficacy measures (EMs) should also be assessed. Methods The clinical relevance of EMs used in one systematic Cochrane review of oral zolmitriptan for migraine headache was evaluated. Results The following EMs were used: pain free at two hours (30%), headache relief at two hours (60%), sustained pain free for 24 hours (19%) and sustained headache relief for 24 hours (39%). These EMs were also used in four other Cochrane reviews of acute migraine treatment. Of these EMs sustained headache relief for 24 h is not judged clinically relevant. Conclusion Pain free and sustained pain free are clinically relevant, but the responses are rather low, demonstrating that there is a need for improvement of acute drug treatment in migraine.

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Guideline Summary for Patients and Their Families

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100118992 ◽

2013 ◽

Vol 40 (S3) ◽

pp. S69-S72

Author(s):

Werner J. Becker ◽

Irene Worthington ◽

Keyword(s):

Migraine Attack ◽

Treatment Guideline ◽

Lifestyle Factors ◽

Migraine Treatment ◽

Acute Migraine ◽

Acute Medication ◽

Preventive Medication ◽

Acute Migraine Treatment

This acute migraine treatment guideline is summarized here to provide information for patients with migraine and their families. Acute migraine medications are used to treat individual migraine attacks at the time of the attack. Most patients with migraine will use an acute medication, but patients with migraine, especially if they have frequent attacks, should also consider whether they could change lifestyle factors which might be making their headache more frequent (skipping meals, not enough sleep, etc), or whether they need a migraine preventive medication. Preventive (or prophylactic) medications are quite different from acute medications. Preventive medications are taken daily to reduce the frequency (number) of migraine attacks, while acute medications are used to reduce or stop the pain of a migraine attack once it has started. It is important that acute medications not be taken too often.

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The Effect and Safety of 5-HT1F Receptor Agonist Lasmiditan on Migraine: A Systematic Review and Meta-Analysis

BioMed Research International ◽

10.1155/2021/6663591 ◽

2021 ◽

Vol 2021 ◽

pp. 1-14

Author(s):

Ping Gu ◽

Cheng Chen ◽

Qian Wu ◽

Changhong Dong ◽

Teng Wang ◽

...

Keyword(s):

Receptor Agonist ◽

Meta Analysis ◽

Safety Data ◽

Risk Of Bias ◽

Migraine Treatment ◽

Controlled Trials ◽

Cochrane Central Register ◽

Acute Migraine ◽

Significant Difference ◽

Global Impression Of Change

Background. Migraine has a great impact on public health. Current acute therapies do not satisfy all migraineurs. The novel serotonin 5-HT1F receptor agonist appears more promising for aborting migraine attacks. Objective. To evaluate the clinical efficacy and safety of lasmiditan in treating acute migraine attacks. Methods. The literature search was performed in PubMed, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) which assessed the effect and safety of lasmiditan on migraine. The risk of bias was assessed using the Cochrane Collaboration’s risk of bias tool. Results were extracted and pooled as risk ratios (RRs) with a fixed or random-effects model. Results. Based on the four included RCTs, pooled estimates showed that lasmiditan with the 50 mg, 100 mg, and 200 mg doses was superior to placebo at 2 h after the first dose in terms of pain freedom, absence of migraine-associated symptoms, headache relief, no/mild disability, and global impression of change (very much/much better) (RRs ranged from 1.13 to 1.96), except for nausea-free and vomiting-free. Both lasmiditan 100 mg and 200 mg resulted in significantly fewer patients using rescue medication (100 mg: RR = 0.75 , 95% CI (0.61, 0.92), P = 0.007 ; 200 mg: RR = 0.81 , 95% CI (0.66, 0.99), P = 0.04 ) at 2-24 h postdose, compared with placebo. Safety data showed that the proportion of patients reporting at least one treatment-emergent adverse event (TEAE) and the incidence of most common TEAEs such as dizziness, paresthesia, fatigue, somnolence, and nausea was higher in the lasmiditan groups (50 mg, 100 mg, and 200 mg), compared with placebo. There was no significant difference between lasmiditan and placebo in terms of cardiovascular-related TEAEs ( RR = 2.75 , 95% CI (0.81, 9.37), P = 0.11 ). Compared with lasmiditan 100 mg, lasmiditan 200 mg was more effective in pain freedom at 2 h after the first dose ( RR = 0.83 , 95% CI (0.74, 0.94), P = 0.004 ) but associated with a higher risk of reporting at least one TEAE ( RR = 0.88 , 95% CI (0.81, 0.96), P = 0.006 ). Conclusions. Lasmiditan with the 50 mg, 100 mg, and 200 mg doses are effective and safe in acute migraine treatment. Lasmiditan 200 mg is more effective than lasmiditan 100 mg in pain freedom, while lasmiditan 100 mg is better tolerated in the short-term follow-up. Further larger sample-size RCTs are required to verify the applicability and tolerability in the long term.

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Efficacy and tolerability of frovatriptan in acute migraine treatment: systematic review of randomized controlled trials

Journal of Clinical Pharmacy and Therapeutics ◽

10.1111/j.1365-2710.2005.00677.x ◽

2005 ◽

Vol 30 (6) ◽

pp. 521-532 ◽

Cited By ~ 19

Author(s):

N. Poolsup ◽

V. Leelasangaluk ◽

J. Jittangtrong ◽

C. Rithlamlert ◽

N. Ratanapantamanee ◽

...

Keyword(s):

Systematic Review ◽

Randomized Controlled Trials ◽

Migraine Treatment ◽

Controlled Trials ◽

Acute Migraine ◽

Randomized Controlled ◽

Acute Migraine Treatment

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Targeted Review: Medications for Acute Migraine Treatment

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100118967 ◽

2013 ◽

Vol 40 (S3) ◽

pp. S10-S32 ◽

Cited By ~ 2

Author(s):

Irene Worthington ◽

Tamara Pringsheim ◽

Marek J. Gawel ◽

Jonathan Gladstone ◽

Paul Cooper ◽

...

Keyword(s):

Clinical Trials ◽

Acute Treatment ◽

Randomized Clinical Trials ◽

Migraine Treatment ◽

Acute Migraine ◽

Double Blind ◽

Strong Recommendation ◽

Combination Analgesics ◽

Quality Evidence ◽

Acute Migraine Treatment

ABSTRACT:Objective:To assess the evidence base for drugs used for acute treatment of episodic migraine (headache on < 14 days a month) in Canada.Methods:A detailed search strategy was employed to find relevant published clinical trials of drugs used in Canada for the acute treatment of migraine in adults. Primarily meta-analyses and systematic reviews were included. Where these were not available for a drug or were out of date, individual clinical trial reports were utilized. Only double-blind randomized clinical trials with placebo or active drug controls were included in the analysis. Recommendations and levels of evidence were graded according to the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, using a consensus group.Results:Eighteen acute migraine medications and two adjunctive medications were evaluated. Twelve acute medications received a strong recommendation with supporting high quality evidence for use in acute migraine therapy (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ASA, ibuprofen, naproxen sodium, diclofenac potassium, and acetaminophen). Four acute medications received a weak recommendation for use with low or moderate quality evidence (dihydroergotamine, ergotamine, codeine-containing combination analgesics, and tramadol-containing combination analgesics). Three of these medications were NOT recommended for routine use (ergotamine, and codeine- and tramadol-containing medications), and strong recommendations were made to avoid use of butorphanol and butalbital-containing medications. Both metoclopramide and domperidone received a strong recommendation for use with acute migraine attack medications where necessary.Conclusion:Our targeted review formulated recommendations for the available acute medications for migraine treatment according to the GRADE method. This should be helpful for practitioners who prescribe medications for acute migraine treatment.

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Optimizing the dose of zolmitriptan (Zomig,* 311C90) for the acute treatment of migraine

Neurology ◽

10.1212/wnl.49.5.1210 ◽

1997 ◽

Vol 49 (5) ◽

pp. 1210-1218 ◽

Cited By ~ 110

Author(s):

A. M. Rapoport ◽

N. M. Ramadan ◽

J. U. Adelman ◽

N. T. Mathew ◽

A. H. Elkind ◽

...

Keyword(s):

Initial Dose ◽

Migraine Headache ◽

Acute Treatment ◽

Dose Range ◽

Acute Migraine ◽

Activity Impairment ◽

Double Blind ◽

Recurrent Headache ◽

Migraine Therapy ◽

Range Finding

This study investigated the efficacy of zolmitriptan (Zomig, formerly 311C90) in acute migraine therapy. Patients with a history of migraine were randomized in a double-blind, multicenter, placebo-controlled, dose range-finding study of oral zolmitriptan 1, 2.5, 5, or 10 mg versus placebo for the treatment of a severe or moderate migraine headache. Patients with persistent or recurrent headache 4 to 24 hours after the initial dose, who did not take escape medication, were eligible to receive a second blinded dose of either zolmitriptan or placebo. Of 1,144 patients treated, 999 evaluable patients completed the study. The headache response rates with zolmitriptan doses ≥ 2.5 mg were 44 to 51% at 1 hour, 65 to 67% at 2 hours, and 75 to 78% at 4 hours (all significantly superior to placebo). Also, zolmitriptan effectively relieved migraine-associated symptoms such as nausea, photophobia and phonophobia, and reduced activity impairment. Rates of headache recurrence, headache persistence, and use of escape medication were lower with zolmitriptan doses ≥ 2.5 mg than with placebo. In patients with persistent or recurrent headache, a second zolmitriptan dose effectively treated both headache and nonheadache symptoms. Zolmitriptan was well tolerated, with a lower incidence of adverse events being reported with doses≤ 2.5 mg than with those ≥5 mg. Zolmitriptan is a well tolerated and effective acute migraine therapy providing rapid relief of migraine headache within 1 hour. A clear dose-response relationship between efficacy and tolerability suggests that 2.5 mg is the optimal initial dose for the acute treatment of a migraine attack.

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