Treatment guidelines for acute migraine attacks

The Treatment Guideline Subcommittee of the Taiwan Headache Society evaluated the medications currently used for acute migraine attacks in Taiwan according to the principles of evidence-based medicine. We have assessed the quality of clinical trials, levels of evidence, and referred to other treatment guidelines proposed by Western countries and Japan. After several panel discussions, we merged opinions from the subcommittee members in order to propose a Taiwan consensus regarding the major roles, recommended levels, clinical efficacy, adverse events and cautions of clinical practice for these medications in treatment of acute migraine attacks. Acute medications currently available in Taiwan can be categorized into "migraine-specific" and "migraine-nonspecific" groups. Migraine-specific triptans and ergotamine, and migraine-nonspecific non-steroidal anti-inflammatory drugs (NSAIDs) have the best levels of evidence, and are recommended as the first-line medications for acute migraine attacks. The administration should follow the concept of "stratified care". For mild to moderate migraine attacks, oral NSAIDs are the first choice; with oral aspirin, combination analgesics, intravenous/intramuscular NSAIDs or ergotamine as alternatives. For moderate to severe attacks, oral or nasal spray triptans and ergotamine are recommended and the suggestion is to administer them in the early stage of migraine attacks. NSAIDs can be used as alternatives. Notably, a combination of a triptan and a NSAID yielded a better efficacy compared with either monotherapy. Parenteral steroid and fluid supply are the first choice in treatment of status migrainosus. Acetaminophen showed poor efficacy for moderate to severe migraine attacks but remains the first choice for children and pregnant women. Opiates are not recommended for acute migraine treatment at the present time because of serious adverse events. To prevent medication-overuse headache, the use of acute treatment should be limited to a maximum often days a month.