New AHS Review of Acute Migraine Treatments

January 21, 2015

The American Headache Society (AHS) has released a new "assessment" of therapies for the acute treatment of migraine — the first update since 2000.

This assessment will form the basis of new guidelines that will translate these evidence-based findings into clinical practice recommendations.

The paper, published online in Headache on January 20, was authored by leading headache specialists Michael J. Marmura, MD, and Stephen D. Silberstein, MD, both from the Jefferson Headache Center, Philadelphia, Pennsylvania, and Todd J. Schwedt, MD, Mayo Clinic Scottsdale, Arizona.

"The new guidelines will help doctors make the best decisions for the acute treatment of patients with migraine," Dr Silberstein told Medscape Medical News. "For example, patients often want narcotics for migraine, but now doctors will have a document which spells out that this is not the best treatment. This can make it easier when having that conversation."

In an accompanying editorial, Dr Silberstein and Dr Marmura report that they used American Academy of Neurology guidelines development procedures to thoroughly review the recent scientific literature.

100% Evidence-Based

"While the previous guidelines were based on both scientific evidence and expert opinion, the new guidelines have been put together purely on scientific evidence," Dr Silberstein explained. "This has led to a different classification system based totally on clinical efficacy."

Dr Marmura added: "The new guidelines are now totally evidence based — with the level A treatments all having shown effectiveness in rigorous clinical trials. Levels B and C include agents which have not got the same level of evidence — B being probably effective and C being possibly effective."

"Many new treatments have become available and been tested in rigorous trials since the last guidelines and there is quite a long list of options in level A," he commented. "These include many new triptans, new formulations of sumatripan, and oral diclofenac."

"Some older treatments, such as butorphanol nasal spray, have been upgraded to level A after having been tested in randomized studies, and others, such as methadone injection, have fallen to level C as their efficacy is based on older trials not done to today's standards," Dr Marmura noted.

The current assessment paper focuses on efficacy, and the authors note that they did not formally incorporate adverse effects and harms into the assessment process.

"Some agents — particularly the opioids — might be in level A or B for efficacy, but they may not necessarily be an appropriate first-line treatment because of side-effects or addictive potential," he said.

The paper concludes: "This evidence base for medication efficacy should be considered along with potential medication side effects, potential adverse events, patient-specific contraindications to use of a particular medication, and drug-to-drug interactions when deciding which medication to prescribe for acute therapy of a migraine attack."

"Clinicians still need to individualize treatment and consider the clinical context of the migraine attack," Dr Marmura elaborated. "In general triptans will often be the best first-line agents — they have good evidence of efficacy and a reasonable adverse event profile."

Dr Silberstein agreed that triptans will be the main first-line agents. "In my view triptans work about two thirds of the time. If they are not working, then I would try one of NSAIDs [nonsteroidal anti-inflammatory drugs] or DHE [dihydroergotamine] formulations with level A evidence."

Dr Marmura added: "Most agents are most effective if used early on in the migraine attack (in the first hour if possible), but may not work if the patient has had migraine for a week and turns up at the ER [emergency room]. In this case prochlorperazine or DHE injections may be the best option even though they are only in level B, as they appear to be more effective in very severe cases."

Table. Level A Treatments: Established as Effective in at Least Two Rigorous Studies

Category Treatments
Analgesics Acetaminophen 1000 mg (for nonincapacitating attacks)
Ergots DHE nasal spray 2 mg and pulmonary inhaler 1 mg

Aspirin 500 mg

Diclofenac 50, 100 mg

Ibuprofen 200, 400 mg

Naproxen 500, 550 mg

Opioids Butorphanol nasal spray 1 mg

Almotriptan 12.5 mg

Eletriptan 20, 40, 80 mg

Frovatriptan 2.5 mg

Naratriptan 1, 2.5 mg

Rizatriptan 5, 10 mg

Sumatriptan oral 25, 50, 100 mg; nasal spray 10, 20 mg; patch 6.5 mg; subcutaneous injection 4, 6 mg

Zolmitriptan nasal spray 2.5, 5 mg; oral 2.5, 5 mg


Acetaminophen/aspirin/caffeine 500/500/130 mg

Sumatriptan/naproxen 85/500 mg


Medications at level B (probably effective) include ergotamine and other forms of DHE; ketoprofen, intravenous and intramuscular ketorolac, flurbiprofen, and intravenous magnesium (in migraine with aura); and the combination of isometheptene compounds, codeine/acetaminophen, and tramadol/acetaminophen.

In addition, the antiemetics prochlorperazine, droperidol, chlorpromazine, and metoclopramide are probably effective (level B).

Medications at level C (possibly effective) include butalbital and butalbital combinations, phenazone, intravenous tramadol, methadone, butorphanol or meperidine injections, intranasal lidocaine, and corticosteroids (including dexamethasone).

Octreotide is listed as "probably ineffective," and ketorolac nasal spray, intravenous acetaminophen, chlorpromazine injection, and intravenous granisetron are classified as "possibly ineffective."

This paper covers only the acute treatment of migraine. The AHS and American Academy of Neurology also recently published joint guidelines on the prevention of migraine attacks.

Dr Marmura has received royalty income from Demos Medical, Cambridge University Press, and MedLink Neurology. 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. Dr Schwedt has received consulting fees and/or honoraria from Allergan Inc, Supernus, and Zogenix. He has received royalty income from UpToDate.

Headache. Published online January 20, 2015. Abstract Editorial


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