When a hemiplegic migraine attack is moderate to severe — or does not respond adequately to oral analgesics and NSAIDs — a more targeted pharmacological step is indicated.
First-line treatment with oral analgesics and NSAIDs — including ASA, ibuprofen, metamizole, diclofenac, or combination analgesic preparations, with or without anti-emetics such as metoclopramide or domperidone for nausea — failed to achieve the expected goal: reduction of headache or freedom from pain within 2 hours of intake. When that threshold is not met, escalation to the next treatment step is appropriate.
The next step uses a specific class of targeted agents — 5-HT1B/1D-agonists — indicated for moderate to severe attacks and for attacks unresponsive to analgesics or NSAIDs. For attacks that include an aura, this class is administered after the aura has abated. The full selection of agents in this class, along with the guidance for choosing among them, is detailed in the structured protocol.
Freedom from pain 2 hours after intake of the targeted agent.
DOI: 10.1177/2514183X1882337
The 5-HT1B/1D-agonists (in alphabetical order) almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan and zolmitriptan are the substances with the best efficacy in acute migraine attacks and should be used in severe headache and in migraine attacks which are unresponsive to analgesics or NSAIDs.
Sumatriptan subcutaneous injection (6 mg) is the most effective therapy of acute migraine attacks.
For safety reasons, patients who suffer migraine with aura should not take a triptan until the aura has abated and the headache started.
Triptans are more effective than analgesics or NSAIDs for the endpoint 'pain-free after 2 h' in most randomized studies.
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