Guidelines for the acute pharmacological treatment of migraine were published in August 2024 by the International Headache Society (IHS) in Cephalalgia.^[1]

For individuals with migraine who do not respond to analgesics or non-steroidal anti-inflammatory drugs (NSAIDs) taken at appropriate doses early in the attack, it is recommended to switch to a triptan for the next attack.

If a triptan taken early after migraine onset is only partially effective, it is suggested to increase the dose to the maximum recommended dose for that triptan during the next attack. If three different triptans do not provide satisfactory results, switching to a different class of acute migraine drugs is advised.

In people with migraine who only partially respond to triptans as single agents, it is suggested to use a combination of oral sumatriptan (50–100 mg) and oral naproxen sodium (550 mg) as first choice. Alternatively, combining a triptan with a fast-release oral NSAID is recommended.

For people with migraine experiencing nausea and/or vomiting that is not manageable with timely intake of acute attack medication, the addition of an antiemetic to analgesics, NSAIDs, or triptans is recommended.

For migraine attacks lasting more than 72 hours (status migrainosus), the use of intramuscular or other forms of administration of NSAIDs or subcutaneous sumatriptan, or oral/intranasal dihydroergotamine, possibly in combination with antiemetics, is recommended.

For treating acute migraine attacks in children and adolescents, paracetamol (15 mg/kg, up to 60 mg/kg per day) or ibuprofen (10 mg/kg, up to 30 mg/kg per day) is recommended. If these are ineffective, triptans can be used as second-line therapy in adolescents. Rizatriptan (5 mg for body weight less than 40 kg, 10 mg for 40 kg or more) or sumatriptan nasal spray (10 mg) are preferred.

For individuals older than 65 years with normal liver function, paracetamol is recommended as first-line therapy. Acetylsalicylic acid and NSAIDs are suggested as second-line options, with monitoring for gastrointestinal and renal or hepatic issues. Triptans may be used as a third-line option for those without uncontrolled hypertension or serious cardiovascular conditions. Lasmiditan and gepants are alternatives for those who cannot use triptans.

For people with acute migraine and a history of stroke, cardiovascular diseases, or uncontrolled hypertension, paracetamol is recommended as the first-line treatment, with lasmiditan or gepants as second-line options.

For women with menstrual migraines, NSAIDs or triptans are recommended as first-line treatments. If these are ineffective, combining triptans with NSAIDs, triptans with antiemetics, or NSAIDs with antiemetics is suggested. Lasmiditan and gepants are additional options.

For pregnant women whose migraine attacks are not controlled by non-pharmacologic methods, paracetamol and triptans can be used cautiously throughout all trimesters. Metoclopramide may be added for nausea, vomiting, or insufficient pain relief. During breastfeeding, paracetamol is preferred.