Acute migraine attack
An episode of unilateral throbbing headache of moderate-to-severe intensity with photo- and phonophobia, often with nausea and vomiting, lasting 4–72 hours. AHS 2024 and EFNS 2022 set first-line acute therapy as simple analgesics (paracetamol, NSAIDs) and/or specific triptans (sumatriptan, rizatriptan, eletriptan) when symptoms persist after 1–2 hours. In severe attacks with nausea, antiemetics (metoclopramide, domperidone) are added. Triptan use exceeding 10 days per month raises the risk of medication-overuse headache.
ICD-10 G43.95 drugs
Also known as: Migraine abortive therapy
Drugs used for this condition
- AAlmotriptanFirst line · Selective serotonin 5HT1B/1D agonists (triptans)First-line for acute moderate-to-severe migraine attack under stratified care (EHF 2022 consensus, 2025 European migraine pharmacotherapy guideline) – alone or together with an NSAID from the onset of the attack. For mild attacks, simple analgesics and NSAIDs come first (ibuprofen 800 mg, naproxen 500 mg, ketorolac). Contraindicated in coronary artery disease, prior myocardial infarction or stroke, uncontrolled hypertension, and peripheral vascular disease; frequent use (more than 10 days per month) provokes medication-overuse headache. Dose 12.5 mg at the first signs of attack; if symptoms persist at 2 hours, may repeat, maximum 25 mg/day. Efficacy – pain relief at 2 hours in 60–70% of patients. Not used for prophylaxis – topiramate, beta-blockers, candesartan, or CGRP monoclonal antibodies are used instead.
- ARizatriptanFirst line · Selective 5-HT1B/1D serotonin receptor agonistFirst-line for acute moderate-to-severe migraine per AHS 2021 and EFNS 2009. The 2016 Cochrane systematic review showed pain-free response at 2 hours with rizatriptan 10 mg in 40% versus 19% on placebo. Among triptans, one of the fastest onsets (especially the MLT orally disintegrating tablet when nausea is present). Take at the first sign of pain, not during aura. If no response at 2 hours, repeat dosing is not recommended.
- ASumatriptanFirst line · Selective 5-HT1B/1D serotonin receptor agonistFirst-line for moderate-to-severe migraine attacks per AHS 2024 and EFNS 2022. The Cochrane meta-analysis showed pain-free response at 2 hours with sumatriptan 100 mg in 38% versus 17% on placebo. Subcutaneous 6 mg gives 70% pain-free response – highest efficacy among triptans. Take at the first sign of pain, not during aura. In pregnant migraineurs, sumatriptan has the largest data set among triptans and is preferred when needed.
- BDihydroergotamineThird line · Ergot alkaloid, 5-HT1B/1D and alpha-adrenoceptor agonistDihydroergotamine is a third-line option for acute migraine when triptans failed or are contraindicated. SEN reserves it for backup use. Available as nasal spray (Migranal), subcutaneous or intramuscular injection. Onset 30 minutes to 2 hours. Maximum 3 mg/day and 6 mg/week.
- CErgotamineThird line · Ergot alkaloid, 5-HT1B/1D and alpha-adrenoceptor agonistErgotamine is a third-line option for acute migraine attacks. SEN reserves it for patients in whom triptans failed or are contraindicated. Onset takes 2–4 hours; effect lasts 6–8 hours. Max 6 mg/day and 10 mg/week; exceeding this causes rebound headache and ergotism risk. Vasoconstrictor action contraindicates use in ischemic heart disease, uncontrolled hypertension and peripheral vascular disease.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit