There is no one-size-fits-all approach. Patients and physicians should keep in mind the following:

1. Early treatment of the attack should be a goal for most patients, as medications, especially triptans, are much more effective if taken early, before the attack is fully established.

2. The response of an individual patient to an acute medication cannot be predicted with certainty. Patients must understand that if the first drug is not effective, there are many other options, and followup is critical for a successful outcome.

3. Some patients have attacks of migraine of differing severity and may need more than one acute treatment option for best results.

4. Medications should be chosen based on the characteristics of the migraine attack. For example, if there is no nausea, oral medications such as triptans are a good choice. Injectable sumatriptan is the most effective but also has the highest rate of side effects. Oral disintegrating triptan tablets (Maxalt and Zomig) may be helpful for patients with mild nausea or whose nausea is worsened by taking fluids, and further, they allow for early treatment even if water is not available. They do not, however, have faster action, as they are not absorbed through the mouth but are rather swallowed and absorbed through the stomach. If nausea is more severe, triptan nasal sprays (Imitrex, Zomig) can be useful. For migraine attacks that build rapidly, are associated with early vomiting or are fully developed upon awakening (morning migraine), injectable sumatriptan has the best chance of providing relief. For attacks that build rapidly but are less severe and are not associated with vomiting, Cambia (a rapidly dissolving NSAID), effervescent aspirin, and the fast-dissolving sumatriptan tablet (Imitrex brand) are preferred.

5. If necessary, two or more acute medications can be combined. Treximet is a combined formulation of sumatriptan and naproxen and is more effective than either drug alone. Metoclopramide (Reglan) could be added to any triptan or NSAID. Caffeine enhances the effectiveness of analgesics, and the combination pill with the brand being Excedrin can work but poses risk of interference with sleep and caffeine withdrawal headache.

6. Avoid acute medication overuse. Only migraine patients get medication-overuse headaches. A study with rheumatoid arthritis patients using opioids showed that there was not an increase of medication-overuse headaches if they did not simultaneously have migraine. Medication overuse is defined by Tylenol or NSAIDs 15 or more days a month, butalbital-containing drugs, opioids, ergotamines, or triptans 10 or more days a month. NSAIDs are least likely to cause medication-overuse headaches. Especially butalbital and opioids should be avoided.

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