Acute treatment for migraine with nonopioid analgesics and antiemetics

See separate advice for a child.

As initial treatment for acute migraine, try a nonopioid analgesic. In adults, use:

1 aspirin soluble 900 to 1000 mg orally. Wait 4 to 6 hours before repeating dose if needed (maximum dose 4 g in 24 hours) migraine (adult) aspirin aspirin aspirin

OR

1 ibuprofen 400 to 600 mg orally. Wait 4 to 6 hours before repeating dose if needed (maximum dose 2.4 g in 24 hours) migraine (adult) ibuprofen ibuprofen ibuprofen

OR

2 diclofenac potassium 50 mg orally. Wait 4 to 6 hours before repeating dose if needed (maximum dose 200 mg in 24 hours)¹ migraine (adult) diclofenac diclofenac diclofenac

OR

2 naproxen 500 to 750 mg orally. Wait 4 to 6 hours before repeating dose if needed (maximum dose 1250 mg in 24 hours) migraine (adult) naproxen naproxen naproxen

OR

2 paracetamol soluble 1 g orally. Wait 4 to 6 hours before repeating dose if needed (maximum dose 4 g in 24 hours). migraine (adult) paracetamol paracetamol paracetamol

When the response to a nonopioid analgesic is suboptimal, consider adding an antiemetic (especially metoclopramide)—the antiemetic can improve treatment response by increasing drug absorption. In general, trial one nonopioid analgesic for a couple of migraine attacks. If this is not effective, change to a different nonopioid analgesic (eg from aspirin to ibuprofen) or a triptan.

Limit nonopioid analgesic use to less than 15 days per month. If used more often, the patient is at risk of medication overuse headache.

Avoid opioid analgesics, as they should only be used when other drugs are not tolerated or are contraindicated—if needed, refer for expert advice.

If the patient has nausea, give an oral antiemetic with the acute migraine treatment. Use:

1 metoclopramide 10 mg orally. If nausea persists, give up to 2 more doses (maximum daily dose 30 mg) nausea due to migraine (adult) metoclopramide

OR

2 domperidone 10 to 20 mg orally. If nausea persists, give up to 2 more doses (maximum daily dose 30 mg)² nausea due to migraine (adult) domperidone

OR

2 ondansetron 4 to 8 mg orally. If nausea persists, give up to 2 more doses (maximum daily dose 16 mg)³ nausea due to migraine (adult) ondansetron

OR

2 prochlorperazine 5 to 10 mg orally. If nausea persists, give up to 2 more doses (maximum daily dose 30 mg). nausea due to migraine (adult) prochlorperazine

If a patient needs treatment for acute migraine on more than 2 to 4 days per month, consider migraine prophylaxis.

¹ If the patient has nausea, diclofenac is available as a rectal preparation. Return

² Evidence shows an increased risk of serious cardiac adverse effects (ventricular arrhythmias, sudden cardiac death) from domperidone at doses over 30 mg daily and in patients older than 60 years. For more information, see the Therapeutic Goods Administration (TGA) Medicines Safety Update. Return

³ Ondansetron is available orally as tablets to swallow, or disintegrating tablets or wafers to dissolve on the tongue. Return