Acute Attack of Migraine - Management

Overview

1. NSAIDs
2. 5-HT1B/1D agonists (triptans)
3. CGRP receptor antagonists (gepants)
4. 5-HT1F agonists (ditans)
5. Dopamine receptor antagonists (antiemetics)

Step-Wise Approach by Severity

Mild Attacks

• Oral analgesics and NSAIDs are effective in about 50-70% of cases
• Aspirin, acetaminophen (paracetamol), ibuprofen, naproxen are first-line options
• The FDA-approved combination of acetaminophen + aspirin + caffeine (e.g., Excedrin) is effective for mild-to-moderate migraine. Caffeine aids absorption, helps induce vasoconstriction, and reduces serotonergic brainstem neuron firing
• Aspirin + metoclopramide is another validated combination
• A stratified care model (choosing medication based on severity and disability from the start) has been shown superior to a step-up approach (starting with NSAID and escalating)

Moderate-to-Severe Attacks

Drug Classes in Detail

1. Triptans (5-HT1B/1D Receptor Agonists) - FIRST LINE

• SC sumatriptan onset: ~20 min
• Oral onset: 1-2 hours

2. Ergot Alkaloids (5-HT1 + α + Dopamine Receptor Agonist)

• Ergotamine: Sublingual or oral + caffeine tablet/suppository. Most effective in early stages. Strict daily and weekly dose limits due to dependence and rebound headaches.
• Dihydroergotamine (DHE): IV or intranasal. Efficacy similar to sumatriptan. Reserved for severe migraine. Nausea is a common adverse effect.

3. Ditans (5-HT1F Receptor Agonists) - Newer Class

• Lasmiditan - selective 5-HT1F agonist
• Thought to reduce activation of trigeminal nerve pain pathways
• Does not cause vasoconstriction - advantage over triptans/ergots
• Indicated for acute migraine when triptans are contraindicated or not tolerated (e.g., significant cardiovascular disease)
• Classified as a controlled substance (abuse potential)
• Can cause significant driving impairment - patients should avoid hazardous activities
• Oral route

4. CGRP Receptor Antagonists (Gepants) - Newer Class

• Rimegepant and ubrogepant - both oral
• CGRP levels are elevated during acute migraine and contribute to neurogenic inflammation
• Indicated for acute migraine when triptans are contraindicated or not tolerated
• Repeat dosing is effective (unlike triptans) - can re-dose at 2 hours
• Rimegepant can also be used for migraine prevention (as can atogepant)
• Adverse effects: nausea, somnolence (low incidence)
• Ubrogepant is contraindicated with strong CYP3A4 inhibitors

5. Antiemetics / Dopamine Receptor Antagonists

• Nausea and vomiting are common symptoms
• Once attack is fully developed, oral drugs are less effective due to decreased GI motility and poor absorption

• Metoclopramide (also has pro-kinetic effect improving absorption of co-administered drugs)
• Prochlorperazine
• Domperidone

Route of Administration

Emergency Department / Status Migrainosus

• IV metoclopramide or prochlorperazine (dopamine antagonists) - first-line in ED
• IV DHE (dihydroergotamine) after antiemetic pretreatment
• IV valproic acid - loading dose 15 mg/kg at 20 mg/min in D5W, followed by 5 mg/kg q8h; an alternative is 1 g in 250 mL NS over 1 hour
• IV/IM ketorolac (NSAID)
• Dexamethasone 10 mg IV before discharge to prevent headache recurrence
• Opioids/opiates should be avoided to minimize risk of medication overuse headache

Non-Pharmacologic Measures

• Rest in a dark, quiet room with ice pack on the head
• Sleep often resolves the attack
• Trigger identification and avoidance
• Stress management: biofeedback, yoga, transcendental meditation
• Regular sleep, meals, exercise, limiting caffeine and alcohol

Practical Prescribing Tips

1. Start treatment early - at first symptom or during aura rather than waiting for full headache
2. Use adequate dosing - under-dosing is a common failure mode
3. Choose route based on associated symptoms - vomiting means oral drugs won't work
4. Warn about medication overuse headache (MOH) - limit acute drug use to ≤10-15 days/month depending on agent
5. Triptans are ineffective for prevention - treat the acute attack only
6. Try multiple triptans before concluding the class doesn't work - individual response varies significantly

Summary of Drug Choice by Clinical Scenario

Tingling Sensation Before a Migraine - Is It Possible?

Understanding Migraine Aura

Types of Aura

• Visual (most common, ~90% of auras) - flashes, zigzag/fortification lines (scintillating scotoma), visual field loss. Occur 20-40 minutes before headache.
• Sensory - paresthesia (tingling), numbness
• Motor - spreading weakness (seen in hemiplegic migraine)
• Speech - mild dysphasia

Sensory Aura - The "Marching" Pattern

• Starts in the fingers/hand, then slowly marches up the arm toward the face
• Can involve the ipsilateral arm, periorbital region (around the eye), or tongue
• The sensation begins as "positive" symptoms first (tingling, pins-and-needles), then transitions to "negative" symptoms (numbness)
• Progresses slowly over 5-20 minutes - this slow march is what distinguishes it from a stroke or seizure

Can Tingling in the Foot Occur?

1. Sensory cortex somatotopy: The sensory homunculus in the parietal cortex maps the body such that the foot and leg are represented on the medial surface (top of the brain), while the hand/arm and face are on the lateral surface. CSD typically starts occipitally and can involve the parietal cortex - theoretically it could reach the foot representation, but this is far less common than hand/face involvement.
2. Basilar-type migraine: A subtype where aura symptoms arise from the brainstem or bilateral hemispheres - can cause bilateral paresthesias including the legs/feet, along with vertigo, tinnitus, diplopia, and dysarthria.
3. Hemiplegic migraine: A rare autosomal dominant subtype where motor weakness and paresthesia can affect an entire side including the leg and foot.
4. Important caution: Tingling confined to the foot only (especially one foot), without other migraine features, is not typical of migraine aura. It raises other diagnoses such as:
   • Peripheral neuropathy
   • Lumbar radiculopathy (L4/L5/S1)
   • Transient ischemic attack (TIA)
   • Multiple sclerosis

Key Diagnostic Clue - Speed of Progression

Clinical Bottom Line

• Tingling before a migraine is a recognized feature of sensory aura in migraine with aura
• The typical distribution is hand → arm → face, not foot
• Tingling in the foot can occur in basilar or hemiplegic migraine subtypes, but is uncommon in typical migraine aura
• The characteristic slow marching quality and positive-then-negative progression of symptoms over minutes distinguishes migraine aura from stroke or seizure
• If tingling is isolated to the foot without typical migraine features, other neurological causes must be excluded