What are the recommended first-line treatments for acute migraine attacks in adults?

The recommended first-line treatments for acute migraine attacks in adults are oral triptans, NSAIDs, aspirin (900 mg), or paracetamol. SIGN guidance recommends aspirin (900 mg), ibuprofen (400 mg, increased to 600 mg if 400 mg is ineffective), or triptans (sumatriptan 50–100 mg first line) as treatment for acute migraine ¹.

Early treatment with triptans while the headache is still mild improves the likelihood of complete pain relief. All evidence was from orally administered drugs ¹.

Combination therapy with an oral triptan and an NSAID or paracetamol can also be considered. NICE and SIGN guidelines highlight the efficacy of combination therapy, especially with a triptan and a long half-life NSAID such as naproxen ¹.

Triptans are recommended as second-line options if initial treatments fail, with sumatriptan (50–100 mg) as the first choice. Several guidelines recommend offering an alternative triptan if the initial one fails ¹.

Anti-emetics such as prochlorperazine 10 mg or metoclopramide 10 mg may be considered as adjuncts, especially if nausea or vomiting are present. They can be added to other treatments, but evidence for independent pain relief is moderate to very low ¹.

Ergots and opioids are not recommended for acute migraine treatment. NICE guidance advises against their use due to high risk of adverse effects ¹.