Treatment of Migraine with Brainstem Aura When Oral Analgesics and NSAIDs Have Not Reduced Headache at 2 Hours
This protocol addresses acute management of migraine with brainstem aura in patients whose attack has not responded adequately to first-line oral analgesics or NSAIDs — specifically when headache reduction is not achieved within two hours of the initial dose.
Previous Line — Failure Condition
Prior therapies: Oral analgesics / NSAIDs — including ASA, ibuprofen, metamizole, diclofenac potassium, combination analgesics, and paracetamol/acetaminophen — with anti-emetics (metoclopramide or domperidone) used when nausea or vomiting was present.
Failure criterion: Insufficient reduction of headache at 2 hours after administration.
Next-Line Approach
When oral analgesics have not provided adequate headache relief, the protocol escalates to a targeted class of acute migraine therapies — 5-HT1B/1D-agonists (triptans) — with specific clinical requirements around the timing of administration relative to the aura phase.
Treatment Goal
Freedom from pain at 2 hours after administration, with defined guidance on recurrence management after initial effectiveness.
References
- 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.
- Eletriptan and rizatriptan are the most effective oral triptans according to results of meta-analyses.
- For safety reasons, patients who suffer migraine with aura should not take a triptan until the aura has abated and the headache started.
- In a meta-analysis, eletriptan 40 mg and rizatriptan 10 mg showed the highest rate of freedom from pain after 2 h, eletriptan also showed the highest rate of freedom from pain over 24 h.
- If headache recurs after initial effectiveness of a triptan, a second dose of the triptan may not be given for at least 2 h.
DOI: 10.1177/2514183X1882337
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