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.
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.
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.
Pregnancy, vascular disease, renal or gastrointestinal disease, adolescence or complex polypharmacy changes routine choice.
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.
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.