01Purpose and principlesWhat the treatment does and how it fits into care.
A useful acute plan is written before the next attack. Confirm which phase the patient recognises, how rapidly disability develops, whether vomiting prevents absorption, and what has already been tried at an adequate dose and time. Discuss a quiet dark environment, hydration according to thirst and maintaining ordinary meals where possible, while avoiding claims that lifestyle alone should stop a biological attack. NICE supports an oral triptan combined with either an NSAID or paracetamol as first-line combination treatment. Some people choose monotherapy because attacks are mild, contraindications narrow choice or they prefer fewer tablets. Provide precise instructions, maximum daily exposure and what to do if pain recurs. A response supports the plan but does not prove the diagnosis.
Route and timing are common reasons for apparent failure. Gastric stasis and vomiting can make late oral doses unreliable. A nasal or subcutaneous triptan, or non-oral antiemetic with a non-oral analgesic, may work when tablets repeatedly fail. If the headache returns after an initial response, a permitted repeat triptan dose may be used after the product-specific interval; repeating a dose after no response at all is often less useful than reviewing diagnosis, timing and a different triptan. Antiemetics can be offered even when nausea is not dominant. Metoclopramide carries acute dystonia and akathisia risk and should be used for short periods; prochlorperazine has extrapyramidal, hypotensive and sedating effects. Rimegepant is a later NICE option within its exact eligibility and commissioning criteria, not a substitute for properly testing first-line treatment. Driving and work advice should reflect both migraine impairment and treatment effects.
Comorbidity shapes the safest option. Triptans are generally avoided in established coronary, cerebrovascular or peripheral arterial disease and uncontrolled hypertension; follow the current product information and formulary. NSAIDs require caution with ulceration, renal impairment, anticoagulation, heart failure, asthma sensitivity and pregnancy. Paracetamol is often preferred during pregnancy, while any triptan or antiemetic choice should be discussed using current obstetric or medicines-in-pregnancy advice. Avoid aspirin under age 16. Ask about over-the-counter combination analgesics and caffeine, because patients may not count them as treatment days. If acute medicines are needed repeatedly, if attacks cause substantial disability despite an optimised plan, or if the person is approaching overuse thresholds, move the consultation towards preventive therapy rather than cycling rescue agents indefinitely.
Key points
- Treat early in the headache phase when the diagnosis and pattern are secure; patients with aura usually take a triptan when headache begins rather than during aura alone.
- NICE recommends combination therapy with an oral triptan plus an NSAID, or an oral triptan plus paracetamol, after discussing preference, comorbidity and adverse effects.
- If one drug is preferred, offer an oral triptan, NSAID, aspirin 900 mg or paracetamol; aspirin is not for people under 16 and may be unsuitable in several adult contexts.
- Consider an antiemetic even without prominent nausea because it treats associated symptoms and may improve gastrointestinal absorption during an attack.
- When oral treatment is ineffective or not tolerated, use non-oral metoclopramide or prochlorperazine and consider adding a non-oral NSAID or triptan where safe.
- Try an alternative triptan if the first is consistently ineffective despite correct timing and dose; for eligible adults, NICE also recommends rimegepant after at least two triptans fail, or when triptans are contraindicated or not tolerated and both NSAIDs and paracetamol have failed.
- Do not offer opioids or ergots for acute migraine: efficacy is poor relative to harms, and repeated use promotes dependence, recurrence and medication-overuse headache.
- Check cardiovascular disease, uncontrolled hypertension, pregnancy, gastrointestinal and renal risk, anticoagulation, interacting serotonergic medicines and previous adverse effects before prescribing.
- Set a monthly ceiling and review trigger for acute medicine use; frequent need indicates prevention and medication-overuse assessment rather than ever-larger rescue supplies.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
A headache matching the person's recurrent migraine phenotype with normal expected recovery and no new red flag is appropriate for their agreed acute plan.
Vomiting, marked nausea, late dosing or rapid escalation can prevent absorption; repeated tablet failure should prompt route and timing review before declaring the drug ineffective.
Pain that resolves and returns within the same attack may permit a second triptan dose after the formulation-specific interval, provided the maximum dose and contraindications are respected.
Increasing headache frequency alongside triptan, opioid, combination-analgesic or simple-analgesic use on many days each month suggests a treatment-amplified cycle requiring a separate withdrawal plan.
Known ischaemic heart disease, stroke, TIA, peripheral arterial disease or uncontrolled hypertension may contraindicate a triptan and should be checked before first prescription or renewal.
Instantaneous onset, fever, persistent neurological abnormality, visual-threat features or a pregnancy-related change overrides the existing migraine plan and requires urgent reassessment.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Treatment and attack timelineFirst step - Why
- Determine whether each medicine was taken early enough, at a therapeutic dose and by an absorbable route.
- Interpretation and limitations
- A drug taken after hours of vomiting is not a fair oral trial; consistent early failure after correct use supports changing triptan or route.
- 02
Acute medicine-day count - Why
- Detect approaching or established medication overuse across prescribed and over-the-counter products.
- Interpretation and limitations
- Count days, not tablet totals, and separate triptans or combination products from simple analgesics because diagnostic overuse thresholds differ.
- 03
Cardiovascular and blood-pressure review - Why
- Identify triptan contraindications and relevant vascular risk before vasoconstrictive treatment.
- Interpretation and limitations
- Established arterial disease or uncontrolled hypertension usually redirects treatment; low-risk asymptomatic patients do not need indiscriminate cardiac testing.
- 04
Renal, gastrointestinal and bleeding-risk assessment - Why
- Assess whether an NSAID or high-dose aspirin is safe for the individual attack plan.
- Interpretation and limitations
- Renal impairment, ulcer history, anticoagulation, heart failure or NSAID-sensitive asthma may favour paracetamol, a triptan alone or specialist alternatives.
- 05
Pregnancy and contraception review - Why
- Align acute treatment with current pregnancy status, pregnancy intention and feeding considerations.
- Interpretation and limitations
- Do not infer safety from prior use; check current UK obstetric or medicines-in-pregnancy guidance and individual exposure context.
04Treatment approachPreparation, options, escalation and aftercare.
01First prescriptionCreate a usable attack planFirst stepMigraine is diagnosed and acute treatment is required.+
- 1Confirm that the current episodes match a stable migraine phenotype and screen for urgent secondary features before discussing rescue medication.
- 2Offer an oral triptan with an NSAID or paracetamol, or a suitable monotherapy option, after checking contraindications and the patient's preference.
- 3Add an antiemetic when useful, specify when to take each component, dose intervals, maxima and the action if vomiting prevents oral absorption.
- 4Agree a diary and review threshold based on treatment days, disability and response so that prevention or overuse management is not delayed.
02Poor responseOptimise before abandoning acute therapyThe first acute regimen gives insufficient relief or intolerable adverse effects.+
- 1Recheck diagnosis, red flags, timing, dose, adherence, vomiting, recurrence and whether the stated outcome was pain freedom, functional recovery or nausea control.
- 2Change to a non-oral route when absorption is the problem, or trial another triptan after a properly used first option repeatedly fails.
- 3Use a safe antiemetic and complementary analgesic class where appropriate, avoiding duplicate NSAIDs and unrecognised paracetamol in combination products.
- 4EscalationEscalate to prevention or specialist review when multiple properly used options fail, attacks are frequent, or contraindications make routine strategies unsafe.
03Special contextAdapt treatment to riskPregnancy, vascular disease, renal or gastrointestinal disease, adolescence or complex polypharmacy changes routine choice.+
- 1Define the relevant risk precisely, including gestation, feeding, arterial diagnosis, blood pressure, ulcer or renal history and interacting medicines.
- 2Choose the lowest-risk evidence-based option with current formulary, product and pregnancy guidance rather than applying a blanket class rule from memory.
- 3Document counselling on adverse effects, driving, maximum use and when a changed attack needs urgent review rather than another rescue dose.
- 4Seek headache, obstetric, paediatric, stroke or medicines-information advice when the safe balance remains uncertain.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Sumatriptan oral
Usually 50 mg at headache onset; some require 100 mg, with one repeat after at least 2 hours if pain recurs, maximum 300 mg daily.Avoid in relevant coronary, cerebrovascular or peripheral arterial disease and uncontrolled hypertension. Severe hepatic impairment is contraindicated; in mild-to-moderate hepatic impairment consider 25–50 mg according to the selected product, and use caution with renal impairment.
Rimegepant
For an eligible adult, use 75 mg as an orodispersible tablet when needed, no more than once daily, following the commissioned formulary and current product information.Check hepatic and renal impairment, pregnancy or breastfeeding, hypersensitivity and clinically important CYP3A4 or transporter interactions; record that the exact NICE TA919 criteria are met.
Ibuprofen
Use a formulary-approved acute dose, commonly 400 mg orally with food, respecting product intervals and the daily maximum.Avoid or modify for peptic ulceration, renal impairment, anticoagulation, heart failure, NSAID-sensitive asthma and pregnancy; never combine multiple NSAIDs.
Paracetamol
Usually 1 g orally at onset in adults at least 50 kg, no more often than every 4–6 hours and maximum 4 g daily.Reduce the dose or maximum for low body weight, liver disease, frailty, malnutrition or harmful alcohol use, and count hidden paracetamol in combination products.
Metoclopramide
A typical adult dose is 10 mg up to three times daily, leaving at least 6 hours between doses even after vomiting; do not exceed the lower of 30 mg or 0.5 mg/kg in 24 hours and do not treat for longer than 5 days. Give an intravenous dose as a slow bolus over at least 3 minutes.Can cause dystonia, akathisia and tardive neurological effects; it is contraindicated in Parkinson's disease and epilepsy. Reduce the total daily dose by 50% when creatinine clearance is 15–60 mL/min, by 75% when it is 15 mL/min or less, and by 50% in severe hepatic impairment, following the selected product and its other contraindications.
Prochlorperazine buccal
Follow the licensed short-course product regimen, commonly 3–6 mg buccally twice daily for a maximum of 2 days.May cause sedation, hypotension, dystonia and other extrapyramidal effects; review interacting antipsychotic or QT-prolonging medicines and individual contraindications.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Use a diary to record time to meaningful relief, pain freedom, functional recovery, recurrence, vomiting and adverse effects for each acute regimen.
- Count days per month of triptan, combination analgesic, opioid and simple analgesic exposure, including non-prescription products.
- Recheck blood pressure and evolving cardiovascular history before continuing triptans when risk status changes.
- Monitor renal, gastrointestinal or bleeding complications when NSAID exposure is recurrent or the patient's comorbidity changes.
- Review after a small number of representative attacks rather than renewing an ineffective plan indefinitely; frequent failure may reflect diagnosis, route, timing or need for prevention.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Early does not mean aura
For migraine with aura, triptans are generally taken at the start of headache because evidence for dosing during aura alone is less reliable and diagnosis may be uncertain.
Absorption can masquerade as resistance
Migraine-related gastric stasis and vomiting reduce tablet delivery. Changing route may transform response without needing a stronger drug class.
Antiemetics do more than comfort
NICE supports an antiemetic even without obvious nausea, reflecting effects on attack symptoms and impaired gastrointestinal handling.
One triptan does not represent all
Patients can respond differently to individual triptans and formulations, so a correctly conducted alternative trial is reasonable after initial failure.
Supply size is a safety intervention
Link quantity to an agreed use ceiling and review. Large automatic repeats can unintentionally sustain medication overuse and postpone preventive care.
08Common pitfallsFrequent interpretation and management errors.
- 01
Escalating treatment for a changed or thunderclap headache before checking whether the episode still fits the established migraine diagnosis.
- 02
Calling tablets ineffective when every dose was taken late after vomiting, without considering nasal, subcutaneous, buccal or other non-oral routes.
- 03
Offering opioids for recurrent migraine and creating dependence, sedation and medication-overuse risk without a durable benefit.
- 04
Prescribing a triptan without checking arterial disease and blood pressure, or an NSAID without reviewing renal, bleeding and pregnancy risk.
- 05
Adding separate analgesics without checking combination remedies, leading to duplicate NSAIDs or inadvertent paracetamol excess.
- 06
Refilling rescue treatment month after month without counting use days, measuring disability or discussing preventive treatment.