Migraine headache in adults

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

presenting to the emergency department with persistent migraine

1st line – rescue therapy

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1st line –

rescue therapy

First-line treatment of adults with acute migraine in the emergency department should include an intravenous anti-emetic (e.g., metoclopramide or prochlorperazine) with or without diphenhydramine.[114][115][116][117]

Promethazine can also be used for the symptomatic relief of nausea. Evidence suggests it may help other migraine symptoms. Prochlorperazine appears to work faster than promethazine but has similar outcomes at 60 minutes.[118]

American Headache Society (AHS) guidelines recommend offering subcutaneous sumatriptan. They also support the use of intravenous administration of ketorolac, valproic acid, haloperidol, or paracetamol.[114]

AHS guidelines state that no recommendation can be made regarding use of intravenous magnesium for adults who present to an emergency department with acute migraine, but that it may be of benefit for patients with migraine with aura.[114]

The American College of Obstetricians and Gynecologists (ACOG) recommends metoclopramide alone or combined with diphenhydramine as first-line treatment for pregnant women.[84] ACOG guidelines suggest cautious use of sumatriptan as an option for patients who are pregnant.[84] Intravenous paracetamol or (in the second trimester only) ketorolac may also be considered. ACOG guidelines suggest cautious short-term use of intravenous magnesium is an option for pregnant women.[84] Intravenous magnesium may cause bone thinning in the developing fetus when used for longer than 5-7 days in a row.[84] Valproic acid and its derivatives are contraindicated during pregnancy.

Primary options

metoclopramide: 10-20 mg intravenously as a single dose

prochlorperazine: 10 mg intravenously/intramuscularly as a single dose

metoclopramide: 10-20 mg intravenously as a single dose

prochlorperazine: 10 mg intravenously/intramuscularly as a single dose

-- AND --

diphenhydramine: 25-50 mg intravenously as a single dose

promethazine: 25 mg intravenously as a single dose

sumatriptan: 6 mg subcutaneously as a single dose

Secondary options

ketorolac: 30-60 mg intramuscularly/intravenously as a single dose

valproic acid: 500-1000 mg intravenously as a single dose

haloperidol: 5 mg intravenously as a single dose

paracetamol: 1000 mg intravenously as a single dose

magnesium sulfate: 1-2 g intravenously as a single dose

Consider – hydration

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Consider –

hydration

Additional treatment recommended for SOME patients in selected patient group

Dehydration is a trigger for migraine attacks, and the nausea and vomiting of migraine may lead to significant dehydration. Therefore hydration with oral or intravenous fluids should be considered for any patient with prolonged migraine headache associated with nausea and vomiting.[87] Hydration improves comfort and may speed resolution of a migraine.

Consider – high-flow oxygen

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Consider –

high-flow oxygen

Additional treatment recommended for SOME patients in selected patient group

May provide effective acute treatment for migraine.[119]

Usually administered via non-rebreather mask at a rate of 15 L/min.

Consider – corticosteroid

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Consider –

corticosteroid

Additional treatment recommended for SOME patients in selected patient group

An intravenous corticosteroid, such as dexamethasone, should be offered to prevent the return of migraine, but frequent use is not recommended as it can result in adrenal suppression, osteoporosis, osteonecrosis, or elevated serum glucose levels. However, irreversible adverse effects such as osteonecrosis have been rarely reported after one dose of dexamethasone.[114]

Oral prednisolone is preferred to dexamethasone in pregnant women due to its safety profile, although effectiveness may be lower. Dexamethasone may be considered with caution for pregnant patients with severe recalcitrant migraine.[84]

Primary options

dexamethasone: 8-16 mg intravenously as a single dose

Secondary options

prednisolone: consult specialist for guidance on dose

ACUTE

mild symptoms: non-pregnant

1st line – non-steroidal anti-inflammatory drug (NSAID)

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1st line –

non-steroidal anti-inflammatory drug (NSAID)

Acute treatment of migraine with NSAIDs is most effective when the medication is used early, while the headache is mild.[91][192][193]

Prescription-strength NSAIDs such as aspirin, diclofenac, ibuprofen, and naproxen have been shown to be effective initial treatments for acute migraine.[34][39][91][92][93][94][95][96] [ ] [ ]

NSAIDs are contraindicated in patients with a history of gastrointestinal bleeding.[194] Excessive use may contribute to the development of renal complications.[195]

Many different NSAIDs are available and most are considered efficacious for migraine; only doses for the most commonly used drugs are shown.

Primary options

aspirin: 900-1000 mg orally as a single dose

diclofenac potassium: 50 mg orally (powder for oral solution) as a single dose

ibuprofen: 400-600 mg orally as a single dose

naproxen: 500-750 mg orally as a single dose

Consider – anti-emetic

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Consider –

anti-emetic

Additional treatment recommended for SOME patients in selected patient group

Consider for patients with nausea and vomiting.[86]

Metoclopramide should be used for up to 5 days only in order to minimise the risk of neurological and other adverse effects.[196]

Primary options

metoclopramide: 5-10 mg orally/intramuscularly/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

prochlorperazine: 5-10 mg orally (immediate-release) every 6-8 hours when required, maximum 40 mg/day

promethazine: 12.5 to 25 mg orally/intramuscularly/intravenously/rectally every 4-6 hours when required, maximum 100 mg/day

Consider – hydration

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Consider –

hydration

Additional treatment recommended for SOME patients in selected patient group

2nd line – paracetamol monotherapy

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2nd line –

paracetamol monotherapy

May be used if non-steroidal anti-inflammatory drugs (NSAIDs) are contraindicated or are not tolerated.[39][86][94] Paracetamol is more effective than placebo in treating migraine, but may be less effective than other simple analgesics, including NSAIDs.

The combination of paracetamol and an anti-emetic has equivalent short-term efficacy to oral sumatriptan, with fewer adverse effects.[97] [ ]

Paracetamol is available as a rectal suppository for patients in whom significant nausea or vomiting precludes oral treatment.

Serious adverse effects are rare with intermittent use. Excessive use can cause medication-overuse headache. Paracetamol is unlikely to cause problems when used during pregnancy.[197][198]

Excessive use of paracetamol may contribute to the development of renal and liver complications.[199][200]

Primary options

paracetamol: 1000 mg orally/rectally as a single dose

Consider – anti-emetic

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Consider –

anti-emetic

Additional treatment recommended for SOME patients in selected patient group

Consider for patients with nausea and vomiting.[86]

Metoclopramide should be used for up to 5 days only in order to minimise the risk of neurological and other adverse effects.[196]

Primary options

metoclopramide: 5-10 mg orally/intramuscularly/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

prochlorperazine: 5-10 mg orally (immediate-release) every 6-8 hours when required, maximum 40 mg/day

promethazine: 12.5 to 25 mg orally/intramuscularly/intravenously/rectally every 4-6 hours when required, maximum 100 mg/day

Consider – hydration

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Consider –

hydration

Additional treatment recommended for SOME patients in selected patient group

3rd line – paracetamol/aspirin/caffeine

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3rd line –

paracetamol/aspirin/caffeine

This proprietary combination is more effective than placebo and non-prescription analgesics alone for acute treatment of mild to moderate migraine.[34][89][90]

The risk-benefit profile of this medication is favourable for intermittent use. Excessive use can cause medication-overuse headache.

Excessive use of analgesics, including aspirin, may contribute to the development of renal complications.[195] Excessive use of paracetamol may contribute to the development of renal and liver complications.[199][200]

Primary options

paracetamol/aspirin/caffeine: consult product literature for guidance on dose

Consider – anti-emetic

Back

Consider –

anti-emetic

Additional treatment recommended for SOME patients in selected patient group

Consider for patients with nausea and vomiting.[86]

Metoclopramide should be used for up to 5 days only in order to minimise the risk of neurological and other adverse effects.[196]

Primary options

metoclopramide: 5-10 mg orally/intramuscularly/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

prochlorperazine: 5-10 mg orally (immediate-release) every 6-8 hours when required, maximum 40 mg/day

promethazine: 12.5 to 25 mg orally/intramuscularly/intravenously/rectally every 4-6 hours when required, maximum 100 mg/day

Consider – hydration

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Consider –

hydration

Additional treatment recommended for SOME patients in selected patient group

moderate to severe symptoms: non-pregnant

1st line – triptan

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1st line –

triptan

Triptans (5HT1 receptor agonists) are the first-line treatment for patients with moderate to severe migraine.[34][86][88][98] They are effective and generally well tolerated, although they are associated with a greater risk of any adverse event, or a treatment-related adverse event, compared with placebo and non-triptans.[99]

Triptans are contraindicated in patients with coronary artery disease, and should be used with caution in patients with cardiovascular risk factors.[34][100]

Early treatment with triptans, while the headache is still mild, improves the likelihood of complete pain relief, lowers the chance of recurrent headache, and decreases the amount of medication needed to treat the entire attack.[34][39][86][95]

All oral triptans have been shown to be effective for the acute treatment of migraine, and choice depends on factors such as availability and patient preference.[34][39][96][98][101]

Alternative routes of administration (e.g., subcutaneous or intranasal sumatriptan, intranasal zolmitriptan) have been shown to be effective for acute migraine attacks. These formulations are particularly useful for patients with severe nausea or vomiting or who have trouble swallowing.[34][39][101]

The individual patient response to any particular triptan cannot be predicted, so if one triptan is ineffective a second one should be trialed.[34][39][86]

Primary options

almotriptan: 6.25 to 12.5 mg orally as a single dose, may repeat after at least 2 hours, maximum 25 mg/day

eletriptan: 20-40 mg orally as a single dose, may repeat after at least 2 hours, maximum 80 mg/day

rizatriptan: 5-10 mg orally as a single dose, may repeat after at least 2 hours, maximum 30 mg/day

sumatriptan: 25-100 mg orally as a single dose, may repeat after at least 2 hours, maximum 200 mg/day; 3-6 mg subcutaneously as a single dose, may repeat after at least 1 hour, maximum 12 mg/day

sumatriptan nasal: (spray) 5-20 mg intranasally as a single dose, may repeat after at least 2 hours, maximum 40 mg/day; (powder inhalation) 22 mg intranasally as a single dose, may repeat after at least 2 hours, maximum 44 mg/day

zolmitriptan: 1.25 to 5 mg orally as a single dose, may repeat after at least 2 hours, maximum 10 mg/day

zolmitriptan nasal: 2.5 to 5 mg intranasally as a single dose, may repeat after at least 2 hours, maximum 10 mg/day

Secondary options

frovatriptan: 2.5 mg orally as a single dose, may repeat after at least 2 hours, maximum 7.5 mg/day

naratriptan: 1 to 2.5 mg orally as a single dose, may repeat after at least 4 hours, maximum 5 mg/day

Consider – anti-emetic

Back

Consider –

anti-emetic

Additional treatment recommended for SOME patients in selected patient group

Consider for patients with nausea and vomiting.[86]

Metoclopramide should be used for up to 5 days only in order to minimise the risk of neurological and other adverse effects.[196]

Primary options

metoclopramide: 5-10 mg orally/intramuscularly/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

prochlorperazine: 5-10 mg orally (immediate-release) every 6-8 hours when required, maximum 40 mg/day

promethazine: 12.5 to 25 mg orally/intramuscularly/intravenously/rectally every 4-6 hours when required, maximum 100 mg/day

Consider – hydration

Back

Consider –

hydration

Additional treatment recommended for SOME patients in selected patient group

Consider – non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Additional treatment recommended for SOME patients in selected patient group

If initial treatment with a triptan alone is ineffective, an NSAID, paracetamol, or paracetamol/aspirin/caffeine may be used as adjunctive therapy. This improves the efficacy of acute treatment, with a minimal increase in adverse effects.[86][95][102][103] Triptans may be available in proprietary combination formulations with an NSAID.

Many different NSAIDs are available and most are considered efficacious for migraine; only doses for the most commonly used drugs are shown.[34][39][91][92][93][94][95][96]

Paracetamol is more effective than placebo in treating migraine, but may be less effective than other simple analgesics. Paracetamol is available as a rectal suppository for patients in whom significant nausea or vomiting precludes oral treatment.

Compared with non-prescription analgesics alone, combinations of caffeine with analgesics shows significantly improved efficacy for the treatment of migraine, with good tolerability in most patients.[34][89][90]

Serious adverse effects of analgesic medications are rare with intermittent use. Excessive use of analgesics, including aspirin, may contribute to the development of renal complications.[195] NSAIDs are contraindicated in patients with a history of gastrointestinal bleeding.[194] Excessive use of paracetamol may contribute to the development of renal and liver complications.[199][200]

Primary options

aspirin: 900-1000 mg orally as a single dose

diclofenac potassium: 50 mg orally (powder for oral solution) as a single dose

ibuprofen: 400-600 mg orally as a single dose

naproxen: 500-750 mg orally as a single dose

Secondary options

paracetamol: 1000 mg orally/rectally as a single dose

Tertiary options

paracetamol/aspirin/caffeine: consult product literature for guidance on dose

Consider – non-invasive neuromodulation

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Consider –

non-invasive neuromodulation

Additional treatment recommended for SOME patients in selected patient group

Adjunctive neuromodulation may reduce acute medication use and so reduce the risk of medication-overuse headache. Approaches shown to be effective and approved for acute migraine treatment are electrical trigeminal nerve stimulation (eTNS), non-invasive vagus nerve stimulation (nVNS), single-pulse transcranial magnetic stimulation (sTMS), and remote electrical neuromodulation (REN).[34][82][96][112][113]

2nd line – lasmiditan

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2nd line –

lasmiditan

Lasmiditan, a first-in-class serotonin 5-HT1F receptor agonist, is effective for the acute treatment of migraine with or without aura in adults, and is recommended as a treatment option if triptans are ineffective or contraindicated.[34][39][82][88][104][105] It does not constrict blood vessels, and appears to be safe for patients with cardiovascular disease.[34][96]

Lasmiditan was associated in trials with significant improvements in pain freedom, pain relief, and relief from the most bothersome symptom at 2 hours after dosing, as well as pain freedom at 1 day and 1 week (compared with placebo).[96][106]

Reported adverse effects were mostly mild (e.g., dizziness, paresthesias, somnolence, fatigue), although clinically meaningful impairment in driving performance has been observed. Patients are advised not to drive for at least 8 hours after using lasmiditan.[34][96][106]

Primary options

lasmiditan: 50-200 mg orally as a single dose, maximum 1 dose/24 hours

Consider – anti-emetic

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Consider –

anti-emetic

Additional treatment recommended for SOME patients in selected patient group

Consider for patients with nausea and vomiting.[86]

Primary options

metoclopramide: 5-10 mg orally/intramuscularly/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

prochlorperazine: 5-10 mg orally (immediate-release) every 6-8 hours when required, maximum 40 mg/day

promethazine: 12.5 to 25 mg orally/intramuscularly/intravenously/rectally every 4-6 hours when required, maximum 100 mg/day

Consider – hydration

Back

Consider –

hydration

Additional treatment recommended for SOME patients in selected patient group

Consider – non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Additional treatment recommended for SOME patients in selected patient group

If initial treatment with lasmiditan alone is ineffective, an NSAID, paracetamol, or paracetamol/aspirin/caffeine may be used as adjunctive therapy.

Many different NSAIDs are available and most are considered efficacious for migraine; only doses for the most commonly used drugs are shown.[34][39][91][92][93][94][95][96]

Primary options

aspirin: 900-1000 mg orally as a single dose

diclofenac potassium: 50 mg orally (powder for oral solution) as a single dose

ibuprofen: 400-600 mg orally as a single dose

naproxen: 500-750 mg orally as a single dose

Secondary options

paracetamol: 1000 mg orally/rectally as a single dose

Tertiary options

paracetamol/aspirin/caffeine: consult product literature for guidance on dose

Consider – non-invasive neuromodulation

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Consider –

non-invasive neuromodulation

Additional treatment recommended for SOME patients in selected patient group

2nd line – calcitonin gene-related peptide (CGRP) antagonist (gepant)

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2nd line –

calcitonin gene-related peptide (CGRP) antagonist (gepant)

CGRP antagonists (also known as gepants) are effective for the acute treatment of migraine with or without aura in adults, and are recommended as a treatment option if triptans are ineffective or contraindicated.[34][39][82][88][104][105] These drugs do not constrict blood vessels, and appear to be safe for patients with cardiovascular disease.[34][96]

Oral CGRP antagonists include rimegepant and ubrogepant. Rimegepant and ubrogepant are associated with significant improvements in pain freedom, pain relief, and the most bothersome (non-pain) symptom at 2 hours, as well as sustained pain freedom at 1 day and at 1 week in trials versus placebo.[34][96] They have shown good safety and tolerability in trials, and are associated with fewer adverse effects than lasmiditan.[34][107] In one study, ubrogepant was significantly more effective than placebo in eliminating headache when given during the prodrome phase.[80]

Zavegepant is an intranasal CGRP antagonist. Zavegepant was associated with significant improvements in pain and symptom relief compared with placebo, and has fewer adverse effects than other intranasal-specific therapies for treating acute migraine.[108][109]

Primary options

rimegepant: 75 mg orally/sublingually as a single dose

ubrogepant: 50-100 mg orally as a single dose, may repeat after at least 2 hours, maximum 200 mg/day

zavegepant nasal: 10 mg (1 spray) in one nostril as a single dose

Consider – anti-emetic

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Consider –

anti-emetic

Additional treatment recommended for SOME patients in selected patient group

Consider for patients with nausea and vomiting.[86]

Primary options

metoclopramide: 5-10 mg orally/intramuscularly/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

prochlorperazine: 5-10 mg orally (immediate-release) every 6-8 hours when required, maximum 40 mg/day

promethazine: 12.5 to 25 mg orally/intramuscularly/intravenously/rectally every 4-6 hours when required, maximum 100 mg/day

Consider – hydration

Back

Consider –

hydration

Additional treatment recommended for SOME patients in selected patient group

Consider – non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Additional treatment recommended for SOME patients in selected patient group

If initial treatment with a calcitonin gene-related peptide (CGRP) antagonist alone is ineffective, an NSAID, paracetamol, or paracetamol/aspirin/caffeine may be used as adjunctive therapy.

Many different NSAIDs are available and most are considered efficacious for migraine; only doses for the most commonly used drugs are shown.[34][39][91][92][93][94][95][96]

Primary options

aspirin: 900-1000 mg orally as a single dose

diclofenac potassium: 50 mg orally (powder for oral solution) as a single dose

ibuprofen: 400-600 mg orally as a single dose

naproxen: 500-750 mg orally as a single dose

Secondary options

paracetamol: 1000 mg orally/rectally as a single dose

Tertiary options

paracetamol/aspirin/caffeine: consult product literature for guidance on dose

Consider – non-invasive neuromodulation

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Consider –

non-invasive neuromodulation

Additional treatment recommended for SOME patients in selected patient group

2nd line – non-invasive neuromodulation

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2nd line –

non-invasive neuromodulation

Neuromodulatory devices may be considered as options for treating acute migraine if triptans are ineffective or contraindicated, and/or if a non-oral treatment is required because of severe nausea or vomiting. Approaches shown to be effective and approved for acute migraine treatment are electrical trigeminal nerve stimulation (eTNS), non-invasive vagus nerve stimulation (nVNS), single-pulse transcranial magnetic stimulation (sTMS), and remote electrical neuromodulation (REN).[34][82][96][112][113]

Consider – anti-emetic

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Consider –

anti-emetic

Additional treatment recommended for SOME patients in selected patient group

Consider for patients with nausea and vomiting.[86]

Primary options

metoclopramide: 5-10 mg orally/intramuscularly/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

prochlorperazine: 5-10 mg orally (immediate-release) every 6-8 hours when required, maximum 40 mg/day

promethazine: 12.5 to 25 mg orally/intramuscularly/intravenously/rectally every 4-6 hours when required, maximum 100 mg/day

Consider – hydration

Back

Consider –

hydration

Additional treatment recommended for SOME patients in selected patient group

Consider – non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Additional treatment recommended for SOME patients in selected patient group

If initial treatment with neuromodulation alone is ineffective, an NSAID, paracetamol, or paracetamol/aspirin/caffeine may be used as adjunctive therapy.

Many different NSAIDs are available and most are considered efficacious for migraine; only doses for the most commonly used drugs are shown.[34][39][91][92][93][94][95][96]

Primary options

aspirin: 900-1000 mg orally as a single dose

diclofenac potassium: 50 mg orally (powder for oral solution) as a single dose

ibuprofen: 400-600 mg orally as a single dose

naproxen: 500-750 mg orally as a single dose

Secondary options

paracetamol: 1000 mg orally/rectally as a single dose

Tertiary options

paracetamol/aspirin/caffeine: consult product literature for guidance on dose

3rd line – ergot derivative

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3rd line –

ergot derivative

Ergot derivatives are approved for the acute treatment of migraine, although triptans, lasmiditan, or CGRP antagonists are the preferred drug options compared to ergot derivatives for most patients requiring migraine-specific treatment, because of both superior efficacy and fewer adverse effects.[34][39][86][110][111]

Dihydroergotamine is the only drug in the class that is commonly used in the US to treat migraine. If used, it is most effective when given early in the headache course. Dihydroergotamine may be used as a parenteral treatment of prolonged headache in the infusion unit or emergency department setting (this use is not approved).[201] Selected patients may be taught to self-administer the drug at home to decrease emergency department use.[202]

Ergot derivatives have agonistic activity at serotonin receptors known to be involved in migraine, but are also active at dopaminergic and adrenergic receptors, causing treatment-limiting adverse effects such as nausea, hypertension, and peripheral vasoconstriction.[203] Ergot derivatives should not be used with triptans.

Dihydroergotamine nasal spray is approved for the acute treatment of migraine with or without aura. In a phase 3 open-label trial, dihydroergotamine nasal spray provided rapid symptom relief in around two-thirds of patients, and was well tolerated.[204][205]

Adverse effects include medication-overuse headache, intense arterial constriction (ergotism), myocardial ischaemia, fetal malformations, and retroperitoneal fibrosis.[206][207]

Primary options

dihydroergotamine: 1 mg subcutaneously/intramuscularly/intravenously as a single dose, may repeat every hour when required, maximum 2 mg/day (intravenously) or 3 mg/day (subcutaneously/intramuscularly) and 6 mg/week (all routes)

dihydroergotamine nasal: (0.5 mg/actuation) 0.5 mg (1 spray) in each nostril initially, may repeat after 15 minutes, maximum 4 sprays/day and 8 sprays/week; (0.725 mg/actuation) 0.725 mg (1 spray) in each nostril initially, may repeat after 1 hour, maximum 4 sprays/day and 6 sprays/week

Consider – anti-emetic

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Consider –

anti-emetic

Additional treatment recommended for SOME patients in selected patient group

Consider for patients with nausea and vomiting.[86]

Metoclopramide should be used for up to 5 days only in order to minimise the risk of neurological and other adverse effects.[196]

Primary options

metoclopramide: 5-10 mg orally/intramuscularly/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

prochlorperazine: 5-10 mg orally (immediate-release) every 6-8 hours when required, maximum 40 mg/day

promethazine: 12.5 to 25 mg orally/intramuscularly/intravenously/rectally every 4-6 hours when required, maximum 100 mg/day

Consider – hydration

Back

Consider –

hydration

Additional treatment recommended for SOME patients in selected patient group

Consider – non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Back

Consider –

non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Additional treatment recommended for SOME patients in selected patient group

If initial treatment with an ergot derivative alone is insufficiently effective, an NSAID, paracetamol, or paracetamol/aspirin/caffeine may be used as adjunctive therapy.

Many different NSAIDs are available and most are considered efficacious for migraine; only doses for the most commonly used drugs are shown.[34][39][91][92][93][94][95][96]

Primary options

aspirin: 900-1000 mg orally as a single dose

diclofenac potassium: 50 mg orally (powder for oral solution) as a single dose

ibuprofen: 400-600 mg orally as a single dose

naproxen: 500-750 mg orally as a single dose

Secondary options

paracetamol: 1000 mg orally/rectally as a single dose

Tertiary options

paracetamol/aspirin/caffeine: consult product literature for guidance on dose

Consider – non-invasive neuromodulation

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Consider –

non-invasive neuromodulation

Additional treatment recommended for SOME patients in selected patient group

pregnant

1st line – non-invasive neuromodulation

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1st line –

non-invasive neuromodulation

Non-invasive neuromodulation is a potential non-pharmacological treatment for acute migraine during pregnancy, although efficacy in pregnant women has not been assessed and evidence for its use in pregnancy is limited.[84]

Approaches shown to be effective and approved for acute migraine treatment are electrical trigeminal nerve stimulation (eTNS), non-invasive vagus nerve stimulation (nVNS), single-pulse transcranial magnetic stimulation (sTMS), and remote electrical neuromodulation (REN).[34][82][96][112][113]

1st line – paracetamol or non-steroidal anti-inflammatory drug (NSAID) or triptan

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1st line –

paracetamol or non-steroidal anti-inflammatory drug (NSAID) or triptan

For pregnant women who wish to receive pharmacotherapy, paracetamol is unlikely to cause problems when used during pregnancy.[197][198] Paracetamol is more effective than placebo in treating migraine, but may be less effective than other simple analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs). Paracetamol is available as a rectal suppository for patients in whom significant nausea or vomiting precludes oral treatment. Serious adverse effects are rare with intermittent use. Excessive use can cause medication-overuse headache and may contribute to the development of renal and liver complications.[199][200]

NSAIDs are not generally recommended for pregnant women; however, the American College of Obstetricians and Gynecologists (ACOG) recommends that NSAIDs may be considered for intractable migraine in the second trimester only.[84]

Sumatriptan (a triptan) may be considered with caution, but it is not suitable for patients with cardiac disease or hypertension.[84] One systematic review concluded that triptans do not appear to increase the risk of pregnancy adverse pregnancy outcomes.[123]

Primary options

paracetamol: 1000 mg orally/rectally as a single dose

Secondary options

aspirin: 900-1000 mg orally as a single dose

diclofenac potassium: 50 mg orally (powder for oral solution) as a single dose

ibuprofen: 400-600 mg orally as a single dose

naproxen: 500-750 mg orally as a single dose

sumatriptan: 25-100 mg orally as a single dose, may repeat after at least 2 hours, maximum 200 mg/day; 3-6 mg subcutaneously as a single dose, may repeat after at least 1 hour, maximum 12 mg/day

Consider – anti-emetic ± diphenhydramine

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Consider –

anti-emetic ± diphenhydramine

Additional treatment recommended for SOME patients in selected patient group

Consider for patients with persistent migraine with nausea and vomiting.

Metoclopramide alone or combined with diphenhydramine is recommended by the American College of Obstetricians and Gynecologists (ACOG) as first-line treatment for pregnant women.[84] Diphenhydramine may also be used with prochlorperazine.

Metoclopramide should be used for up to 5 days only in order to minimise the risk of neurological and other adverse effects.[196]

Primary options

metoclopramide: 5-10 mg orally/intramuscularly/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

and

diphenhydramine: 25-50 mg orally/intramuscularly/intravenously every 4-6 hours when required, maximum 300 mg/day (oral) or 400 mg/day (intramuscular/intravenous)

Secondary options

prochlorperazine: 5-10 mg orally (immediate-release) every 6-8 hours when required, maximum 40 mg/day

and

diphenhydramine: 25-50 mg orally/intramuscularly/intravenously every 4-6 hours when required, maximum 300 mg/day (oral) or 400 mg/day (intramuscular/intravenous)

Consider – hydration

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Consider –

hydration

Additional treatment recommended for SOME patients in selected patient group

Consider – magnesium

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Consider –

magnesium

Additional treatment recommended for SOME patients in selected patient group

Intravenous magnesium may be used as a short-term treatment in pregnant women, especially when pre-eclampsia and migraine coexist.[84][208] However, intravenous magnesium may cause bone thinning in the developing fetus when used for longer than 5-7 days in a row.

Primary options

magnesium sulfate: 1-2 g intravenously as a single dose

Consider – non-invasive neuromodulation

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Consider –

non-invasive neuromodulation

Additional treatment recommended for SOME patients in selected patient group

Efficacy in pregnant women has not been assessed and evidence for its use in pregnancy is limited.[84]

ONGOING

frequent recurring severe/disabling symptoms not linked to menstrual cycle: non-pregnant

1st line – trigger avoidance

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1st line –

trigger avoidance

Consideration of preventive treatment is recommended if any of the following apply: migraine attacks interfere significantly with patient’s daily activities despite acute treatment; frequent attacks; contraindication to, adverse effects with, failure of, or overuse of acute treatments.[34]

Encourage patients to maintain a lifestyle that may help avoid migraines: regular meals, good sleep hygiene, avoid volume depletion, regular exercise, and identify and avoid specific migraine triggers (e.g., through use of a headache diary).[84]

Various factors may act as migraine triggers. However, evidence from randomised controlled trials is lacking. Reported triggers include: high caffeine intake or sudden caffeine withdrawal; specific foods (changes in diet may improve headache frequency or severity, but more evidence is needed); alcohol; changes in weather; high altitude; specific odours.[128][129][130][131][132]

Patients should be educated about trigger avoidance, and encouraged to keep a headache diary so that triggers can be identified and avoided if possible. However, in some cases avoiding triggers may not be realistic.[39][129]

Consider – non-pharmacological therapies

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Consider –

non-pharmacological therapies

Additional treatment recommended for SOME patients in selected patient group

Non-pharmacological therapies are especially appropriate for those who wish to avoid or do not tolerate drug therapy.[34][39][82]

Inadequate sleep, stress, depression, anxiety, and medication overuse are risk factors for poor outcome in prospective studies; non-pharmacological treatments to address these problems may improve outcomes.[126][129]

Biofeedback, cognitive behavioural therapy (CBT), and relaxation training may help some people.[34][82][126][133][134] Mindfulness-based therapies also have some evidence of effectiveness.[34][126]

Physical activity is important. There is some evidence that aerobic exercise, yoga, and strength training may decrease migraine frequency and the number of migraine days.[126][136][137][138][139]

Acupuncture may be useful for patients who do not want to use prophylactic drugs or in whom prophylactic drugs are ineffective.[39][82] One Cochrane review reported that adding acupuncture to the symptomatic treatment of attacks reduced the frequency of headaches, although when compared with prophylactic drug treatment this effect was not maintained at follow-up (3 months).[141] Other systematic reviews have suggested that acupuncture may be an effective and safe prophylactic treatment for migraine, but the quality of the evidence is low.[142][143]

1st line – calcitonin gene-related peptide (CGRP) antagonist (preventive)

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1st line –

calcitonin gene-related peptide (CGRP) antagonist (preventive)

Pharmacotherapy for migraine prophylaxis is recommended if trigger avoidance and non-pharmacological therapies are ineffective, or the patient prefers pharmacotherapy. The choice of preventive treatment should be individualised, based on proven efficacy, patient preference and headache profile, drug adverse effects, and the presence or absence of coexisting or comorbid conditions.[34][39][82][125][126][127]

CGRP antagonists are recommended as a first-line pharmacological therapy for migraine prevention by the American Headache Society (AHS); there is substantial evidence for their efficacy, safety, and tolerability, compared with other first-line therapies.[34][82][125][126][127][144][145][146][147] CGRP antagonists for migraine prophylaxis include oral CGRP antagonists (also known as gepants) and CGRP antagonist monoclonal antibodies.[125]

Oral CGRP antagonists for migraine prophylaxis include atogepant and rimegepant.[125] Both drugs have been shown to reduce the mean number of migraine days per month in trials.[145][149][150][151][152][153] They are generally safe and well tolerated for migraine prevention.[154]

CGRP antagonist monoclonal antibodies (e.g., erenumab, fremanezumab, galcanezumab, eptinezumab) are another option. They are administered subcutaneously or intravenously depending on the drug. All four drugs have been demonstrated in randomised controlled trials to reduce monthly migraine days in patients with episodic or chronic migraine, and are safe and well tolerated.[34][144][145][154][155][156][157] Real-world data support trial results, although evidence is limited.[158] There is preliminary evidence that switching to an alternative CGRP antagonist monoclonal antibody after a lack of response to a first may be effective for some patients.[159][160][161]

Treatment should be started at a low dose and re-evaluated after an adequate trial period (at least 8 weeks).[34][126] The optimal duration of preventive treatment is unknown. Once an effective treatment is found, most experts recommend continuing it for at least 4-6 months. At that time, the dose can be slowly lowered over weeks or months, while monitoring any change in headache frequency and resuming full treatment if necessary.[34] Some patients whose headaches are extremely disabling or troublesome may prefer to stay on preventive treatment indefinitely.[34] However, tolerance to preventive therapies may limit their effectiveness.[148]

Primary options

atogepant: episodic: 10-60 mg orally once daily; chronic: 60 mg orally once daily

rimegepant: 75 mg orally/sublingually once daily on alternate days

erenumab: 70-140 mg subcutaneously once monthly

fremanezumab: 225 mg subcutaneously once monthly; or 675 mg subcutaneously every 3 months

galcanezumab: 240 mg subcutaneously as a loading dose, followed by 120 mg subcutaneously once monthly

eptinezumab: 100 mg intravenously every 3 months, may increase to 300 mg every 3 months

Plus – trigger avoidance

Back

Plus –

trigger avoidance

Treatment recommended for ALL patients in selected patient group

Consider – non-pharmacological therapies

Back

Consider –

non-pharmacological therapies

Additional treatment recommended for SOME patients in selected patient group

Biofeedback, cognitive behavioural therapy (CBT), and relaxation training may help some people.[34][82][126][133][134] Mindfulness-based therapies also have some evidence of effectiveness.[34][126]

Physical activity is important. There is some evidence that aerobic exercise, yoga, and strength training may decrease migraine frequency and the number of migraine days.[126][136][137][138][139]

2nd line – anticonvulsant (preventive)

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2nd line –

anticonvulsant (preventive)

Anticonvulsants are an alternative treatment option for migraine prophylaxis. The choice of preventive treatment should be individualised, based on proven efficacy, patient preference and headache profile, drug adverse effects, and the presence or absence of coexisting or comorbid conditions.[34][39][82][125][126]

Topiramate is effective in reducing migraine headache days and generally well tolerated, although adverse events may result in treatment discontinuation.[34][127][162][163] [ ] It is associated with weight loss, and is especially useful in patients who are overweight or unwilling to take drugs that might cause weight gain. In some countries, topiramate is contraindicated in women of childbearing age unless the conditions of a pregnancy prevention programme are fulfilled.

Valproate semisodium (a valproic acid derivative) is also recommended for migraine prevention.[34][127][147][163][170] It has been associated with hepatotoxicity and hepatic failure, pancreatitis, and polycystic ovary syndrome.[209][210] Valproic acid and its derivatives must not be used in female patients of childbearing potential unless other options are unsuitable, there is a pregnancy prevention programme in place, and certain conditions are met. Precautionary measures may also be required in male patients owing to a potential risk that use in the 3 months leading up to conception may increase the likelihood of neurodevelopmental disorders in their children. Regulations and precautionary measures for female and male patients may vary between countries, with some countries taking a more heightened precautionary stance, and you should consult your local guidance for more information.

Primary options

topiramate: 25 mg orally (immediate-release) once daily at bedtime for 1 week initially, increase gradually according to response, maximum 200 mg/day given in 2 divided doses

valproate semisodium: 250 mg orally (delayed-release) twice daily initially, increase gradually according to response, maximum 1000 mg/day

Plus – trigger avoidance

Back

Plus –

trigger avoidance

Treatment recommended for ALL patients in selected patient group

Consider – non-pharmacological therapies

Back

Consider –

non-pharmacological therapies

Additional treatment recommended for SOME patients in selected patient group

Biofeedback, cognitive behavioural therapy (CBT), and relaxation training may help some people.[34][82][126][133][134] Mindfulness-based therapies also have some evidence of effectiveness.[34][126]

Physical activity is important. There is some evidence that aerobic exercise, yoga, and strength training may decrease migraine frequency and the number of migraine days.[126][136][137][138][139]

2nd line – beta-blocker (preventive)

Back

2nd line –

beta-blocker (preventive)

Beta-blockers are an alternative treatment option for migraine prophylaxis. The choice of preventive treatment should be individualised, based on proven efficacy, patient preference and headache profile, drug adverse effects, and the presence or absence of coexisting or comorbid conditions.[34][39][82][125][126]

Propranolol and timolol are approved for migraine prophylaxis. Metoprolol, nadolol, and atenolol also have evidence of benefit.[28][34][127][162][163][172][147] Beta-blockers commonly cause bradycardia and/or hypotension, which may limit the maximum dose.

Primary options

propranolol: 80 mg/day orally (immediate-release) given in 2-4 divided doses initially, increase gradually according to response, maximum 240 mg/day

timolol: 10 mg orally twice daily initially, increase gradually according to response, maximum 30 mg/day

Secondary options

atenolol: 50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day

metoprolol: 25 mg orally (immediate-release) twice daily initially, increase gradually according to response, maximum 200 mg/day

nadolol: 40-80 mg orally once daily initially, increase gradually according to response, maximum 240 mg/day

Plus – trigger avoidance

Back

Plus –

trigger avoidance

Treatment recommended for ALL patients in selected patient group

Consider – non-pharmacological therapies

Back

Consider –

non-pharmacological therapies

Additional treatment recommended for SOME patients in selected patient group

Biofeedback, cognitive behavioural therapy (CBT), and relaxation training may help some people.[34][82][126][133][134] Mindfulness-based therapies also have some evidence of effectiveness.[34][126]

Physical activity is important. There is some evidence that aerobic exercise, yoga, and strength training may decrease migraine frequency and the number of migraine days.[126][136][137][138][139]

2nd line – candesartan (preventive)

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2nd line –

candesartan (preventive)

Candesartan (an angiotensin-II receptor antagonist) is an alternative treatment option for migraine prophylaxis. The choice of preventive treatment should be individualised, based on proven efficacy, patient preference and headache profile, drug adverse effects, and the presence or absence of coexisting or comorbid conditions.[34][39][82][125][126]

Randomised controlled trials have demonstrated that candesartan is effective for the prevention of migraine.[173][174][175]

Primary options

candesartan: 4-8 mg orally once daily initially, increase gradually according to response, maximum 16 mg/day

Plus – trigger avoidance

Back

Plus –

trigger avoidance

Treatment recommended for ALL patients in selected patient group

Consider – non-pharmacological therapies

Back

Consider –

non-pharmacological therapies

Additional treatment recommended for SOME patients in selected patient group

Biofeedback, cognitive behavioural therapy (CBT), and relaxation training may help some people.[34][82][126][133][134] Mindfulness-based therapies also have some evidence of effectiveness.[34][126]

Physical activity is important. There is some evidence that aerobic exercise, yoga, and strength training may decrease migraine frequency and the number of migraine days.[126][136][137][138][139]

2nd line – antidepressant (preventive)

Back

2nd line –

antidepressant (preventive)

Tricyclic antidepressants or serotonin-noradrenaline reuptake inhibitors (SNRIs) are alternative treatment options for migraine prophylaxis. The choice of preventive treatment should be individualised, based on proven efficacy, patient preference and headache profile, drug adverse effects, and the presence or absence of coexisting or comorbid conditions.[34][39][82][125][126]

Tricyclic antidepressants are thought to prevent migraine by inhibiting serotonin and noradrenaline reuptake. Amitriptyline has been reported to be effective in migraine prevention, but trials have been low quality.[34][127][176] May be useful in patients who have coexistent tension-type headaches.[211]

SNRIs are another option. Data suggest that venlafaxine is as effective as amitriptyline for migraine prevention.[177] There is also some evidence that duloxetine is effective for migraine prevention.[127][178][179] These drugs may be especially useful for patients with comorbid depression.

Primary options

amitriptyline: 10-25 mg orally once daily at bedtime initially, increase gradually according to response, maximum 150 mg/day

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 150 mg/day

duloxetine: 30 mg orally once daily at bedtime initially, increase gradually according to response, maximum 60 mg/day

Plus – trigger avoidance

Back

Plus –

trigger avoidance

Treatment recommended for ALL patients in selected patient group

Consider – non-pharmacological therapies

Back

Consider –

non-pharmacological therapies

Additional treatment recommended for SOME patients in selected patient group

Biofeedback, cognitive behavioural therapy (CBT), and relaxation training may help some people.[34][82][126][133][134] Mindfulness-based therapies also have some evidence of effectiveness.[34][126]

Physical activity is important. There is some evidence that aerobic exercise, yoga, and strength training may decrease migraine frequency and the number of migraine days.[126][136][137][138][139]

2nd line – botulinum toxin (preventive)

Back

2nd line –

botulinum toxin (preventive)

Botulinum toxin is an alternative treatment option for migraine prophylaxis. The choice of preventive treatment should be individualised, based on proven efficacy, patient preference and headache profile, drug adverse effects, and the presence or absence of coexisting or comorbid conditions.[34][39][82][125][126]

Botulinum toxin type A has been shown to reduce migraine attacks compared with placebo, to be well tolerated, and to improve quality of life.[34][126][146][180][181] [ ] It is recommended as a treatment option for migraine prevention in US guidelines.[34] It is also recommended for treatment of chronic migraine (headache occurring on ≥15 days per month for > 3 months) in European and Canadian guidelines.[162][182]

Response to treatment should be evaluated regularly, taking into account that any effect will wear off over time, and treatment should be stopped if the patient does not respond to the first two to three treatment cycles.[182]

Primary options

botulinum toxin type A: consult specialist for guidance on dose

Plus – trigger avoidance

Back

Plus –

trigger avoidance

Treatment recommended for ALL patients in selected patient group

Consider – non-pharmacological therapies

Back

Consider –

non-pharmacological therapies

Additional treatment recommended for SOME patients in selected patient group

Biofeedback, cognitive behavioural therapy (CBT), and relaxation training may help some people.[34][82][126][133][134] Mindfulness-based therapies also have some evidence of effectiveness.[34][126]

Physical activity is important. There is some evidence that aerobic exercise, yoga, and strength training may decrease migraine frequency and the number of migraine days.[126][136][137][138][139]

frequent recurring severe/disabling symptoms linked to menstrual cycle: non-pregnant

1st line – hormonal therapy

Back

1st line –

hormonal therapy

The choice of preventive treatment should be individualised, based on proven efficacy, patient preference and headache profile, drug adverse effects, and the presence or absence of coexisting or comorbid conditions.[34][39][82][125][126]

Women with menstrual migraine should be considered for hormonal therapy to suppress menses if medically appropriate.[27][184] A thorough history should be obtained, and Medical Eligibility Criteria for contraceptive use applied, to determine safe use of contraception for menstrual suppression.[185]

Combined hormonal contraceptives are contraindicated in women who have migraine with aura due to an increased risk of cerebrovascular events.[186] Women with migraine with aura should be offered pharmacological treatments other than cycle control.

Various combined oral contraceptive formulations are available. Consult your local drug information source for suitable options and doses.

Plus – trigger avoidance

Back

Plus –

trigger avoidance

Treatment recommended for ALL patients in selected patient group

Consider – non-pharmacological therapies

Back

Consider –

non-pharmacological therapies

Additional treatment recommended for SOME patients in selected patient group

Biofeedback, cognitive behavioural therapy (CBT), and relaxation training may help some people.[34][82][126][133][134] Mindfulness-based therapies also have some evidence of effectiveness.[34][126]

Physical activity is important. There is some evidence that aerobic exercise, yoga, and strength training may decrease migraine frequency and the number of migraine days.[126][136][137][138][139]

Consider – triptan (preventive)

Back

Consider –

triptan (preventive)

Additional treatment recommended for SOME patients in selected patient group

Evidence shows that frovatriptan is effective, and zolmitriptan and naratriptan are probably effective, for the short-term prevention of menstrual migraine.[27][34][39][163][187]

Primary options

frovatriptan: 2.5 mg orally once or twice daily for 6 days; start 2 days prior to onset of menses

Secondary options

zolmitriptan: 2.5 mg orally twice or three times daily for 7 days; start 2 days prior to onset of menses

naratriptan: 1 mg orally twice daily for 5 days; start 2 days prior to onset of menses

Consider – magnesium (preventive)

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Consider –

magnesium (preventive)

Additional treatment recommended for SOME patients in selected patient group

Oral magnesium may be used as a preventive treatment for migraine headache in women with menstrual-related headaches.[188] Prolonged oral use of magnesium can cause diarrhoea.

Primary options

magnesium oxide: consult product literature for guidance on dose

frequent recurring severe/disabling symptoms: pregnant

1st line – trigger avoidance

Back

1st line –

trigger avoidance

Consider – non-pharmacological therapies

Back

Consider –

non-pharmacological therapies

Additional treatment recommended for SOME patients in selected patient group

Non-pharmacological therapies are suggested as a first-line preventive treatment for pregnant women.[39][84]

Biofeedback, cognitive behavioural therapy (CBT), and relaxation training may help some people.[34][82][126][133][134] Mindfulness-based therapies also have some evidence of effectiveness.[34][126]

Physical activity is important. There is some evidence that aerobic exercise, yoga, and strength training may decrease migraine frequency and the number of migraine days.[126][136][137][138][139]

2nd line – specialist referral for preventive pharmacotherapy

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2nd line –

specialist referral for preventive pharmacotherapy

Specialist advice should be sought if pharmacological preventive treatment for migraine is needed during pregnancy. No medication is completely free of risk, and decisions should be made on an individual basis, balancing the risk of the untreated headache disorder as a threat to the health of the mother and unborn child against the risk of the treatment, and taking into account the patient's values and priorities.[84][85]

There is limited evidence on the efficacy and safety of the use of medications for headache prevention in pregnancy. American College of Obstetricians and Gynecologists (ACOG) guidelines note that beta-blockers have evidence of relative safety in pregnancy for other indications.[84] One review concluded that, of medication commonly used for migraine prevention, propranolol has the best evidence for safety during pregnancy.[189] One systematic review noted that anticonvulsants, venlafaxine, tricyclic antidepressants, and beta-blockers may all be associated with fetal/child adverse effects.[190] Topiramate, valproate semisodium, and candesartan are contraindicated in pregnancy. Calcitonin gene-related peptide (CGRP) antagonists have not been studied in pregnant women with migraine. Some CGRP antagonists have been shown to cross the placenta in animal studies, but their effects on the developing human fetus are unknown. CGRP antagonist monoclonal antibodies may have a very long half-life (28 days or more), resulting in a prolonged elimination time after discontinuing treatments.

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Migraine headache in adults

Treatment algorithm

presenting to the emergency department with persistent migraine

rescue therapy

Primary options

Secondary options

hydration

high-flow oxygen

corticosteroid

Primary options

Secondary options

mild symptoms: non-pregnant

non-steroidal anti-inflammatory drug (NSAID)

Primary options

anti-emetic

Primary options

hydration

paracetamol monotherapy

Primary options

anti-emetic

Primary options

hydration

paracetamol/aspirin/caffeine

Primary options

anti-emetic

Primary options

hydration

moderate to severe symptoms: non-pregnant

triptan

Primary options

Secondary options

anti-emetic

Primary options

hydration

non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Primary options

Secondary options

Tertiary options

non-invasive neuromodulation

lasmiditan

Primary options

anti-emetic

Primary options

hydration

non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Primary options

Secondary options

Tertiary options

non-invasive neuromodulation

calcitonin gene-related peptide (CGRP) antagonist (gepant)

Primary options

anti-emetic

Primary options

hydration

non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Primary options

Secondary options

Tertiary options

non-invasive neuromodulation

non-invasive neuromodulation

anti-emetic

Primary options

hydration

non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Primary options

Secondary options

Tertiary options

ergot derivative

Primary options

anti-emetic

Primary options

hydration

non-steroidal anti-inflammatory drug (NSAID) or paracetamol or paracetamol/aspirin/caffeine

Primary options

Secondary options

Tertiary options

non-invasive neuromodulation

pregnant

non-invasive neuromodulation

paracetamol or non-steroidal anti-inflammatory drug (NSAID) or triptan

trigger avoidance