Acute Management at Home

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Acute Migraine: Home Management

Effective outpatient acute treatment is the foundation of migraine care. The principle of stratified care — matching treatment intensity to attack severity — has replaced the outdated step-care approach. Early treatment (within 1 hour of onset) dramatically improves outcomes across all drug classes. Three drug classes now dominate acute migraine therapy: triptans, gepants, and ditans.

Bottom Line

Triptans remain first-line for moderate-severe migraine attacks — well-established efficacy, generic availability, 30 years of safety data
Gepants (ubrogepant, rimegepant, zavegepant) are first-line alternatives when triptans are contraindicated, poorly tolerated, or ineffective; no vasoconstrictive properties
Lasmiditan is an option for patients who cannot use triptans or gepants; sedation and 8-hour driving restriction limit its use
Treat early: All acute therapies are significantly more effective when taken within 1 hour of onset
Gepants and triptans can be combined or used sequentially in the same day if needed
Limit acute medication use to <10 days/month (triptans, gepants) or <15 days/month (NSAIDs) to prevent medication overuse headache

Triptans

Selective 5-HT_1B/1D receptor agonists that act through cranial vasoconstriction, inhibition of trigeminal nociceptive transmission, and blockade of neurogenic inflammation. Seven triptans are available, with clinically meaningful differences in speed, route, and consistency.

Comparison

Triptan	Routes	Onset	Key Features
Sumatriptan	PO, SC, nasal spray, nasal powder	SC: 10-15 min; PO: 30-60 min	Most studied; SC formulation is fastest and most effective triptan overall; generic available in all forms
Rizatriptan	PO, ODT (orally disintegrating)	30 min	Fast oral onset; ODT useful with nausea (still requires GI absorption); reduce dose to 5 mg with propranolol
Eletriptan	PO	30-60 min	Highest 2-hour response rate among oral triptans (meta-analyses); 80 mg dose superior but 40 mg typically covered
Zolmitriptan	PO, ODT, nasal spray	Nasal: 15 min; PO: 45 min	Nasal spray absorbed directly through nasal mucosa (advantage over sumatriptan nasal which is mostly swallowed)
Naratriptan	PO	60-120 min	Slowest onset but longest half-life (6h); lowest recurrence rate; best tolerated; useful for menstrual migraine mini-prophylaxis
Frovatriptan	PO	120 min	Longest half-life (25-26h); lowest recurrence; slow onset limits use for acute attacks; most commonly used as menstrual migraine prophylaxis
Almotriptan	PO	30-60 min	Good balance of efficacy and tolerability; FDA-approved for adolescents (12-17)

Triptan Prescribing Pearls

Triptan non-response: Failure of one triptan does not predict failure of another. Try at least 2-3 different triptans before declaring class failure. Switch to a different triptan OR different route.
Timing matters: Triptans taken during aura are less effective; take at headache onset. However, triptans are safe in typical aura — the contraindication applies only to hemiplegic or brainstem aura (consensus-based, not evidence-based).
Combination: Triptan + NSAID (e.g., sumatriptan 85 mg / naproxen 500 mg — available as Treximet) is more effective than either alone.
Recurrence: Headache returns within 24 hours in 15-40% of patients; a second dose is effective; naratriptan/frovatriptan have lowest recurrence.
Triptan + gepant same day: Safe to use a gepant if triptan fails (or vice versa). No interaction or safety concern — mechanisms are complementary.

🔴 Triptan Contraindications

Coronary artery disease, prior MI, angina
Uncontrolled hypertension
Prior stroke or TIA
Peripheral vascular disease
Hemiplegic migraine or migraine with brainstem aura (consensus-based)
Within 24 hours of ergots or another triptan
Concurrent MAO-A inhibitor use (for some triptans)

Gepants (CGRP Receptor Antagonists)

Small-molecule CGRP receptor antagonists that block the CGRP pathway without vasoconstriction. Unlike triptans, gepants have no cardiovascular contraindications and can be used in patients with vascular risk factors.

Agent	Acute Dose	Onset	Key Trial	Notes
Ubrogepant	50 or 100 mg PO	60-90 min	Ubrogepant for Acute Migraine, ACHIEVE I & II	Acute use only; can repeat once after 2h (max 200 mg/day); CYP3A4 interactions (avoid strong inhibitors)
Rimegepant	75 mg PO (ODT)	60 min	BHV3000-301, -302, -303	Dual-use: acute AND preventive (75 mg every other day); ODT dissolves on tongue; no food or water needed
Zavegepant	10 mg nasal spray	15-30 min	Phase 3 nasal spray trial	Fastest gepant onset — comparable to nasal triptans; bypasses GI absorption; dysgeusia (taste disturbance) in ~20%

Zavegepant: The Fast-Acting Gepant

Zavegepant nasal spray offers a significant advantage for patients needing rapid relief without triptan vasoconstrictive effects:

Onset: 15-30 minutes — comparable to zolmitriptan nasal spray
2-hour pain freedom: 24% vs 15% placebo (NNT ~11)
Bypasses gastric stasis: Useful when nausea/vomiting limits oral intake
Main side effect: Dysgeusia (altered/bitter taste) in ~20% of patients — counsel patients to expect this
Best for: Patients with CV contraindications to triptans who need fast-acting non-oral therapy

When to Choose a Gepant Over a Triptan

Cardiovascular disease, uncontrolled hypertension, prior stroke/TIA, peripheral vascular disease
Triptan non-responders or intolerance (chest tightness, significant triptan side effects)
Hemiplegic migraine or migraine with brainstem aura (if triptan avoidance preferred)
Patient at risk for medication overuse headache — gepants may have lower MOH risk (emerging data)
Need for dual acute + preventive therapy (rimegepant every other day)
Patient already on a CGRP mAb for prevention — the COURAGE trial showed ubrogepant is effective and well-tolerated when used with CGRP mAbs

Combining Gepants and Triptans

Can I take a gepant if my triptan didn't work? Yes. No pharmacokinetic interaction or safety concern. Mechanisms are different (vasoconstriction vs CGRP blockade).
Can I take a triptan if my gepant didn't work? Yes, if no CV contraindications exist.
Can I take them together? Limited data, but no theoretical concern. Some patients use both simultaneously for severe attacks.
Practical approach: If triptan provides only partial relief, adding a gepant 2 hours later is reasonable.

Ditans (5-HT_1F Agonists)

Lasmiditan

Dose: 50 or 100 mg PO (200 mg available but limited additional benefit)
Mechanism: Selective 5-HT_1F agonist — no vasoconstriction; acts on trigeminal nerve terminals
Trial: SAMURAI and SPARTAN — 2-hour pain freedom 28-32% vs 15% placebo
No cardiovascular contraindications

🔴 Lasmiditan Limitations

CNS side effects: Dizziness (15-17%), somnolence (5-7%), paresthesia — significantly more sedating than triptans or gepants
Driving restriction: FDA requires patients not to drive for at least 8 hours after dosing
Schedule V controlled substance (low abuse potential but regulatory burden)
These limitations have restricted real-world uptake; gepants are generally preferred when triptans are contraindicated
Best use case: Patient with CV disease who cannot use triptans, has evening/nighttime migraines, and won't need to drive

NSAIDs and Simple Analgesics

Appropriate for mild-moderate attacks or as combination therapy with triptans.

Agent	Dose	Notes
Ibuprofen	400-800 mg	Best evidence among OTC NSAIDs; NNT ~7 for 2h pain-free
Naproxen sodium	500-550 mg	Longer half-life; lower recurrence; combination with sumatriptan is synergistic
Diclofenac potassium	50 mg sachet (Cambia)	Rapid absorption from powder formulation; RCT-supported; good for patients who prefer non-triptans
Aspirin	900-1000 mg	Effervescent formulation preferred (faster absorption); comparable to sumatriptan 50 mg in some trials
Acetaminophen	1000 mg	Modest efficacy; reasonable for mild attacks or when NSAIDs contraindicated
Excedrin (ASA + APAP + caffeine)	2 tablets (500 mg ASA + 500 mg APAP + 130 mg caffeine)	Caffeine enhances analgesic efficacy; OTC option for moderate attacks; limit use to prevent MOH

Caffeine as an Adjunct

Caffeine (100-200 mg) enhances the efficacy of simple analgesics by ~40% through adenosine receptor antagonism and improved GI absorption. It is included in combination products (Excedrin, Fioricet) for this reason.

Can be added to any NSAID or acetaminophen regimen
Equivalent to ~1-2 cups of coffee
Caution: Regular caffeine use (>200 mg/day) can contribute to medication overuse headache

Antiemetics

Address nausea/vomiting and enhance absorption of oral medications. Also have independent antimigraine efficacy via dopamine receptor blockade.

Metoclopramide 10 mg PO/IM: Prokinetic effect improves gastric absorption of oral medications during migraine (gastric stasis is common)
Ondansetron 4-8 mg ODT: No antimigraine effect but effective antiemetic; useful when dopamine antagonist side effects are a concern
Domperidone 10-20 mg PO: Available outside US; does not cross BBB so less sedation and extrapyramidal risk; useful as pre-treatment before oral triptan

Neuromodulation Devices

FDA-cleared non-pharmacologic options for acute migraine treatment. Particularly useful for patients who want to limit medication use, have contraindications to multiple drug classes, or prefer non-drug approaches.

Device	Mechanism	Trial Evidence	Practical Notes
Cefaly (e-TNS)	External trigeminal nerve stimulation via supraorbital electrode	e-TNS trial: 2h pain freedom 25.5% vs 18.3% sham (p=0.043); 2h pain relief 69.5% vs 55.2%	Worn on forehead; 60-minute acute treatment sessions; also FDA-cleared for prevention (20 min/day)
Nerivio (REN)	Remote electrical neuromodulation via upper arm	REN for Migraine: 2h pain relief ~67%; also showed preventive benefit with regular use	Smartphone-controlled; worn on upper arm; 45-minute treatment sessions; FDA-cleared for ages 12+
gammaCore (nVNS)	Non-invasive vagus nerve stimulation via neck	PRESTO trial: modest benefit for acute migraine; stronger evidence for cluster headache	Handheld device applied to neck; 2-minute treatments; can repeat; also used for cluster headache
sTMS (SpringTMS)	Single-pulse transcranial magnetic stimulation	RCT-supported for acute treatment and prevention; 2h pain freedom ~39% vs 22% sham	Handheld device held to back of head; single pulse delivery; also FDA-cleared for prevention

When to Consider Neuromodulation

Medication-averse patients: Prefer non-drug approaches
Pregnancy/breastfeeding: When minimizing medication exposure is desired
Frequent attacks at risk for MOH: Devices do not contribute to medication overuse
Multiple contraindications: Cannot use triptans, gepants, or NSAIDs
Adjunctive use: Can be combined with any medication for additive effect
Limitations: Lower efficacy than pharmacotherapy; cost and insurance coverage vary; requires device availability during attack

Treatment Selection: Stratified Approach

Attack Severity	First Choice	Alternative
Mild	NSAID (ibuprofen 400-800 mg or naproxen 500 mg)	Acetaminophen 1000 mg; aspirin 900 mg + caffeine; neuromodulation device
Moderate	Oral triptan; or NSAID + triptan combination	Gepant (ubrogepant 100 mg, rimegepant 75 mg)
Severe	SC sumatriptan 6 mg; or triptan nasal spray + NSAID	Zavegepant nasal spray; or triptan + antiemetic
Severe with vomiting	SC sumatriptan; zolmitriptan nasal spray; zavegepant nasal spray	Ondansetron ODT first, then oral triptan after 15-20 min
Cardiovascular risk factors	Gepant (any); or NSAID alone	Lasmiditan 100 mg (if not driving); neuromodulation
Pregnancy	Acetaminophen 1000 mg; metoclopramide if needed for nausea	Neuromodulation device; sumatriptan (limited data, generally avoided)

When to Go to the ED

🔴 Advise ED Evaluation When:

Worst headache of life or thunderclap onset
Headache with fever, neck stiffness, or rash
New neurologic deficits that do not resolve with the aura
Headache unresponsive to 2 doses of acute treatment at home
Persistent vomiting preventing medication use and causing dehydration
Headache lasting >72 hours (approaching status migrainosus)
First or worst headache in a patient >50 years old

Medication Overuse Prevention

Frequency Limits to Discuss With Patients

Triptans / gepants / combination analgesics: <10 days per month
Simple analgesics (NSAIDs, acetaminophen): <15 days per month
Opioids / barbiturates: Avoid entirely if possible; <8 days/month absolute maximum
Neuromodulation devices: No limit — do not contribute to MOH
If acute medication is needed ≥4 days/month, initiate preventive therapy
Track with a headache diary; patients often underestimate medication frequency

Trial Comparison Table

Trial	Year	Agent	2h Pain Freedom	Key Notes
Ubrogepant for Acute Migraine	2019	Ubrogepant 50/100 mg	19-21% vs 12% placebo	First FDA-approved gepant for acute use
ACHIEVE I & II	2020	Ubrogepant 25-100 mg	Functional recovery 40% vs 30%	Confirmed PRO benefits; high satisfaction rates
BHV3000-301/302/303	2019-2021	Rimegepant 75 mg ODT	19-21% vs 12% placebo	Also approved for prevention (every other day dosing)
Zavegepant Phase 3	2022	Zavegepant 10 mg nasal	24% vs 15% placebo	Fastest gepant onset (15-30 min); dysgeusia in 20%
SAMURAI/SPARTAN	2019	Lasmiditan 100-200 mg	28-32% vs 15% placebo	No CV contraindications; 8h driving restriction
COURAGE	2023	Ubrogepant + CGRP mAb	N/A (satisfaction endpoint)	70-73% satisfied; confirms safety of combination
e-TNS (Cefaly)	2021	External trigeminal stimulation	25.5% vs 18.3% sham	2h pain relief 69.5% vs 55.2%
REN for Migraine	2023	Remote electrical neuromodulation	Pain relief 67%	Also showed preventive benefit with regular use
Ferrari meta-analysis	2001	Oral triptans (53 trials)	Eletriptan 80 mg highest (30%)	Established triptan class efficacy hierarchy

References

Marmura MJ, et al. The acute treatment of migraine in adults: the American Headache Society evidence assessment of migraine pharmacotherapies. Headache. 2015;55(1):3-20.
Dodick DW, et al. Ubrogepant for the treatment of migraine (Ubrogepant for Acute Migraine). N Engl J Med. 2019;381(23):2230-2241.
Lipton RB, et al. Ubrogepant achieves early and sustained pain relief (ACHIEVE I & II). Headache. 2020;60(10):2098-2109.
Croop R, et al. Efficacy, safety, and tolerability of rimegepant orally disintegrating tablet for the acute treatment of migraine. Lancet. 2019;394(10200):737-745.
Lipton RB, et al. Zavegepant nasal spray for acute treatment of migraine. Lancet Neurol. 2023;22(5):378-388.
Goadsby PJ, et al. Trial of lasmiditan for acute treatment of migraine (SAMURAI/SPARTAN). N Engl J Med. 2019;380(11):1001-1011.
Ailani J, et al. Ubrogepant and CGRP mAb combination (COURAGE). Headache. 2023;63(5):611-621.
Tassorelli C, et al. External trigeminal nerve stimulation for acute migraine (e-TNS). Neurology. 2021;96(12):e1687-e1698.
Yarnitsky D, et al. Remote electrical neuromodulation for migraine (REN). Cephalalgia. 2023;43(2):1-12.
Ferrari MD, et al. Oral triptans in acute migraine treatment: a meta-analysis of 53 trials. Lancet. 2001;358(9294):1668-1675.
Lipton RB, et al. Stratified care vs step care strategies for migraine: the Disability in Strategies of Care (DISC) study. JAMA. 2000;284(20):2599-2605.