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The principles of acute treatment include: use evidence‐based treatments when possible and appropriate; treat early after the onset of a migraine attack; choose a nonoral route of administration for selected patients; account for tolerability and safety issues; consider self‐administered rescue treatments; and avoid overuse of acute medications.
Depending on the initial treatment, options for outpatient rescue include SC sumatriptan, DHE injection or intranasal spray, or corticosteroids (eg, dexamethasone, IM ketorolac); inpatient options may include parenteral formulations of triptans, DHE, antiemetics, NSAIDs (eg, ketorolac), anticonvulsants (eg, valproate sodium and topiramate [not in women of childbearing potential who are not using an appropriate method of birth controlMigraine patients who need to use acute treatments on a regular basis should be instructed to limit treatment to an average of 2 headache days per week, and patients observed to be exceeding this limit should be offered preventive treatment.Response to acute treatment of migraine can be assessed in many ways, but the efficacy endpoints typically used in clinical trials may not fully reflect the outcomes valued by patientsEmerging agents with novel mechanisms of action that have demonstrated efficacy for the acute treatment of migraine include the small molecule CGRP receptor antagonists, ubrogepantPatients who have contraindications to the use of triptans or who have failed to respond to or tolerate at least 2 oral triptans, as determined by either a validated acute treatment patient reported outcome questionnaire (eg, Migraine Treatment Optimization Questionnaire [mTOQ], Migraine Assessment of Current Therapy [Migraine‐ACT], Patient Perception of Migraine Questionnaire‐Revised [PPMQ‐R], Functional Impairment Scale [FIS], Patient Global Impression of Change [PGIC]) or healthcare provider attestation, are eligible for ubrogepant, rimegepant, lasmiditan, or a neuromodulation device. The choice of treatment should be based on evidence of efficacy, provider experience, tolerability, patient preference, headache subtype, comorbid and coexistent disease, concomitant medications, and the potential for childbearing.


Expert clinicians and researchers in the field of headache medicine from across North America and the European Union provided input and feedback.The principles of pharmacologic preventive treatment of migraine with oral treatments have been as follows: use evidence‐based treatments when possible and appropriate; start with a low dose and titrate slowly; reach a therapeutic dose if possible; allow for an adequate treatment trial duration; establish expectations of therapeutic response and adverse events; and maximize adherence.



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