ACP guideline offers advice, evidence on treating acute episodic migraines
The new guideline recommends adding a triptan if nonpregnant adult patients with moderate to severe episodic migraines do not have a response to NSAID or acetaminophen therapy.
ACP issued two new recommendations for outpatient treatment of acute episodic migraines in nonpregnant adults.
The clinical guideline is meant for physicians and other clinicians treating adults with acute episodic migraine headache (defined as one to 14 headache days per month) in outpatient settings. It was published March 18 by Annals of Internal Medicine.
First, ACP recommends that clinicians add a triptan to an NSAID alone to treat moderate to severe acute episodic migraine headache in outpatient settings for nonpregnant adults who have not responded adequately to an NSAID (strong recommendation; moderate-certainty evidence). Second, the College suggests adding a triptan to acetaminophen for patients who do not respond adequately to acetaminophen (conditional recommendation; low-certainty evidence).
To develop the recommendations, ACP experts evaluated pharmacologic treatments known to be effective for migraine using the best available comparative effectiveness evidence of benefits and harms and patients' values and preferences, in order to prioritize the most effective treatments.
An accompanying editorial notes that the ACP recommendations recognize that acute treatment of migraine may involve a stepped-care approach. It also points out that the recommendations for the most part align with the 2024 International Headache Society (IHS) guidelines with the key exception that IHS recommends triptan monotherapy if a simple analgesic is insufficient, with subsequent optimization of triptan dose and route of administration and then trials of three different triptans before a trial of sumatriptan with naproxen or addition of another NSAID.
The editorial stated, “As we await evidence to fill the gaps about the comparative effectiveness of newer migraine medications, clinicians need to think beyond guidelines to optimize the treatments for individual patients with each subsequent encounter.”
ACP published a companion guideline on Feb. 4, offering new recommendations for the prevention of episodic migraine in nonpregnant adults, accompanied by an analysis of economic evidence for migraine treatments.