American Headache Society Evidence Assessment

The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies

Michael J. Marmura MD

Corresponding Author

Michael J. Marmura MD

Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, USA

Address all correspondence to Michael J. Marmura, 900 Walnut Street Suite 200, Philadelphia, PA 19107, USA.Search for more papers by this author
Stephen D. Silberstein MD, FACP

Stephen D. Silberstein MD, FACP

Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA

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Todd J. Schwedt MD, MSCI

Todd J. Schwedt MD, MSCI

Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, USA

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First published: 20 January 2015
Citations: 391
Conflict of Interest: Dr. Marmura has received royalty income from Demos Medical, Cambridge University Press, and MedLink Neurology. Dr. Schwedt has received consulting fees and/or honoraria from Allergan, Inc., Supernus, and Zogenix. He has received royalty income from UpToDate. Dr. Silberstein has received consulting fees and/or honoraria from Allergan, Inc., Amgen, Avanir Pharmaceuticals, Inc., eNeura Inc, ElectroCore Medical LLC, Medscape, LLC, Medtronic, Inc, Mitsubishi Tanabe Pharma America, Inc., Neuralieve, NINDS, Pfizer, Inc, Supernus Pharmaceuticals, Inc., and Teva Pharmaceuticals. His employer, Jefferson University Hospitals, receives research support from Allergan, Inc, Amgen, Cumberland Pharmaceuticals, Inc, ElectroCore Medical, LLC, Labrys Biologics, Eli Lilly and Company, Merz Pharmaceuticals, and Troy Healthcare.
Financial Support: Supported by the American Headache Society.

Abstract

The study aims to provide an updated assessment of the evidence for individual pharmacological therapies for acute migraine treatment. Pharmacological therapy is frequently required for acutely treating migraine attacks. The American Academy of Neurology Guidelines published in 2000 summarized the available evidence relating to the efficacy of acute migraine medications. This review, conducted by the members of the Guidelines Section of the American Headache Society, is an updated assessment of evidence for the migraine acute medications. A standardized literature search was performed to identify articles related to acute migraine treatment that were published between 1998 and 2013. The American Academy of Neurology Guidelines Development procedures were followed. Two authors reviewed each abstract resulting from the search and determined whether the full manuscript qualified for review. Two reviewers studied each qualifying full manuscript for its level of evidence. Level A evidence requires at least 2 Class I studies, and Level B evidence requires 1 Class I or 2 Class II studies. The specific medications – triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan [oral, nasal spray, injectable, transcutaneous patch], zolmitriptan [oral and nasal spray]) and dihydroergotamine (nasal spray, inhaler) are effective (Level A). Ergotamine and other forms of dihydroergotamine are probably effective (Level B). Effective nonspecific medications include acetaminophen, nonsteroidal anti-inflammatory drugs (aspirin, diclofenac, ibuprofen, and naproxen), opioids (butorphanol nasal spray), sumatriptan/naproxen, and the combination of acetaminophen/aspirin/caffeine (Level A). Ketoprofen, intravenous and intramuscular ketorolac, flurbiprofen, intravenous magnesium (in migraine with aura), and the combination of isometheptene compounds, codeine/acetaminophen and tramadol/acetaminophen are probably effective (Level B). The antiemetics prochlorperazine, droperidol, chlorpromazine, and metoclopramide are probably effective (Level B). There is inadequate evidence for butalbital and butalbital combinations, phenazone, intravenous tramadol, methadone, butorphanol or meperidine injections, intranasal lidocaine, and corticosteroids, including dexamethasone (Level C). Octreotide is probably not effective (Level B). There is inadequate evidence to refute the efficacy of ketorolac nasal spray, intravenous acetaminophen, chlorpromazine injection, and intravenous granisetron (Level C). There are many acute migraine treatments for which evidence supports efficacy. Clinicians must consider medication efficacy, potential side effects, and potential medication-related adverse events when prescribing acute medications for migraine. Although opioids, such as butorphanol, codeine/acetaminophen, and tramadol/acetaminophen, are probably effective, they are not recommended for regular use.