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Pharmacological Acute Migraine Treatment Strategies: Choosing the Right Drug for a Specific Patient

  • Irene Worthington (a1), Tamara Pringsheim (a2), Marek J. Gawel (a1) (a3) (a4), Jonathan Gladstone (a1) (a5), Paul Cooper (a6), Esma Dilli (a7), Michel Aube (a8), Elizabeth Leroux (a9), Werner J. Becker (a2) and on behalf of the Canadian Headache Society Acute Migraine Treatment Guideline Development Group...



In our targeted review (Section 2), 12 acute medications received a strong recommendation for use in acute migraine therapy while four received a weak recommendation for use. Strong recommendations were made to avoid use of two other medications, except for exceptional circumstances. Two anti-emetics received strong recommendations for use as needed.


To organize the available acute migraine medications into acute migraine treatment strategies in order to assist the practitioner in choosing a specific medication(s) for an individual patient.


Acute migraine treatment strategies were developed based on the targeted literature review used for the development of this guideline (Section 2), and a general literature review. Expert consensus groups were used to refine and validate these strategies.


Based on evidence for drug efficacy, drug side effects, migraine severity, and coexistent medical disorders, our analysis resulted in the formulation of eight general acute migraine treatment strategies. These could be grouped into four categories: 1) two mild-moderate attack strategies, 2) two moderate-severe attack or NSAID failure strategies, 3) three refractory migraine strategies, and 4) a vasoconstrictor unresponsive-contraindicated strategy. In addition, strategies were developed for menstrual migraine, migraine during pregnancy, and migraine during lactation. The eight general treatment strategies were coordinated with a “combined acute medication approach” to therapy which used features of both the “stratified” and the “step care across attacks” approaches to acute migraine management.


The available medications for acute migraine treatment can be organized into a series of strategies based on patient clinical features. These strategies may help practitioners make appropriate acute medication choices for patients with migraine.

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Corresponding author

Division of Neurology, 12th Floor, Foothills Hospital, 1403 29th St NW, Calgary, Alberta, T2N 2T9, Canada


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