Synopsis
Select safe, early and route-appropriate treatment for an individual migraine attack, add antiemetic support when useful, and prevent rescue therapy from creating medication-overuse headache.
- 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.
Key red flags
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.
Investigation priorities
Determine whether each medicine was taken early enough, at a therapeutic dose and by an absorbable route.
Management branches
Migraine is diagnosed and acute treatment is required.
- Confirm that the current episodes match a stable migraine phenotype and screen for urgent secondary features before discussing rescue medication.
- Offer an oral triptan with an NSAID or paracetamol, or a suitable monotherapy option, after checking contraindications and the patient's preference.
- Add an antiemetic when useful, specify when to take each component, dose intervals, maxima and the action if vomiting prevents oral absorption.
- Agree a diary and review threshold based on treatment days, disability and response so that prevention or overuse management is not delayed.
Pregnancy, vascular disease, renal or gastrointestinal disease, adolescence or complex polypharmacy changes routine choice.
- Define the relevant risk precisely, including gestation, feeding, arterial diagnosis, blood pressure, ulcer or renal history and interacting medicines.
- Choose the lowest-risk evidence-based option with current formulary, product and pregnancy guidance rather than applying a blanket class rule from memory.
- Document counselling on adverse effects, driving, maximum use and when a changed attack needs urgent review rather than another rescue dose.
Key medicines
Sumatriptan oralUsually 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.
RimegepantFor 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.