Drug
|
Quality of evidence*
|
Scientific effect*
|
Clinical impression of effect*
|
Adverse effects
|
Role (by consensus)
|
| Triptans (serotonin1B/1D receptor agonists) |
|
|
|
|
|
| Sumatriptan nasal spray |
A |
+++ |
+++ |
Occasional |
Moderate-to-severe migraine. Useful when nonoral route needed. Less severe migraine when nonopiate medications fail. |
| Oral triptans |
|
|
|
|
Moderate-to-severe migraine. Less severe migraine when nonopiate medications fail. |
| Naratriptan |
A |
++ |
++ |
Infrequent |
|
| Rizatriptan |
A |
+++ |
+++ |
Occasional |
|
| Sumatriptan |
A |
+++ |
+++ |
Occasional |
|
| Zolmitriptan |
A |
+++ |
+++ |
Occasional |
|
| Sumatriptan SC |
A |
+++ |
+++ |
Frequent |
Moderate-to-severe migraine. Useful when nonoral route needed. Less severe migraine when nonopiate medications fail. |
| Ergot alkaloids and derivatives |
|
|
|
|
|
| DHE IV |
B |
++ |
+++ |
Frequent |
Low recurrence. |
| DHE SC/IM |
B |
+++/++ |
+++ |
Occasional |
Moderate-to-severe migraine. Less severe migraine when nonopiate medications fail. |
| DHE IV plus antiemetics |
B |
+++ |
+++ |
Frequent |
Status migrainosus. Therapy of choice in emergency department. |
| DHE nasal spray |
A |
++ |
++ |
Occasional |
Moderate-to-severe migraine. Less severe migraine when nonopiate medications fail. |
|
|
|
|
|
Low recurrence. |
| Ergotamine |
B |
+ |
++ |
Frequent |
Consider for selected patients with moderate-to-severe migraine. |
| Ergotamine plus caffeine |
|
|
|
|
|
| Antiemetics |
|
|
|
|
|
| Chlorpromazine IM/IV |
C/B |
++ |
++ |
Mild to moderate |
Adjunct therapy. May be choice for acute therapy. |
| Metoclopramide IM |
B |
+ |
+ |
Infrequent to occasional |
Adjunct therapy. May be choice for acute therapy. |
| PR/IV |
B |
++ |
?/++ |
|
|
| Prochlorperazine PR/IM |
B |
+++ |
+/++ |
Occasional |
IM/IV adjunct first-line therapy in emergency department or office; consider PR as adjunct. |
| IV |
B |
+++ |
+++ |
Frequent |
|
| NSAIDs and nonopiate analgesics |
|
|
|
|
|
| Acetaminophen |
B |
0 |
+ |
Infrequent |
Pregnant migraineur. |
| Ketorolac IM |
B |
+ |
++ |
Infrequent |
Consider in emergency department. |
| Oral NSAIDS |
|
|
|
Occasional |
First-line for mild-to-moderate migraine. |
| Aspirin |
A |
++ |
++ |
|
|
| Diclofenac K |
B |
++ |
++ |
|
|
| Flurbiprofen |
B |
+ |
++ |
|
|
| Ibuprofen |
A |
++ |
++ |
|
|
| Naproxen |
B |
+ |
++ |
|
|
| Naproxen sodium |
A |
++ |
++ |
|
|
| Combination analgesics |
|
|
|
|
|
| Acetaminophen, aspirin, caffeine |
A |
+++ |
++ |
Infrequent |
First-line for migraine. |
| Barbiturate hypnotics |
|
|
|
|
|
| Butalbital, ASA, caffeine |
C |
? |
+++ |
Occasional |
Occasional use for moderate-to-severe migraine. Limit use due to risk of overuse. |
| Butalbital, ASA, caffeine, codeine |
B |
++ |
+++ |
|
|
| Opiate analgesics |
|
|
|
|
|
| Butorphanol nasal spray |
A |
+++ |
+++ |
Frequent |
Moderate to severe migraine; rescue therapy. |
|
|
|
|
|
Limit use. |
| Opiates—oral combinations |
A |
++ |
++ |
Occasional |
Moderate to severe migraine; rescue therapy. |
| Acetaminophen, codeine combinations |
|
|
|
|
Limit use. |
| Opiates—parenteral |
B |
++ |
++ |
Frequent |
Reserved for emergency department use or rescue medication. |
| Butorphanol IM |
|
|
|
|
Limit use. |
| Meperidine IM/IV |
|
|
|
|
|
| Methadone IM |
|
|
|
|
|
| Other medications |
|
|
|
|
|
| Corticosteroids |
C |
+ |
++ |
Infrequent |
Rescue therapy in status migrainosus. |
| IV plus antiemetics |
|
|
|
|
|
| Dexamethasone |
|
|
|
|
|
| Hydrocortisone |
|
|
|
|
|
| Isometheptene compound |
B |
+ |
++ |
Infrequent |
Mild-to-moderate headache. |
Lidocaine IN
|
B
|
++
|
?
|
Frequent
|
Uncertain.
|
| * See Appendix 2 for explanations of quality of evidence, scientific effect, and clinical impression of effect. |
| ? = not known; NSAIDs = nonsteroidal anti-inflammatory drugs; ASA = acetylsalicylic acid. |
