Treatment should be prioritized as a joint venture between doctor and patient. The vast majority of migraine attacks are and should be treated by the patients at home or at work. The following discussion focuses on information necessary to the physician in helping patients choose the best treatment for their migraine attacks (for treatment in a surgery setting or in an emergency department, see Chapter 140).

As mentioned in the discussion of general and pharmacologic migraine management (see Chapter 47), acute treatment should be tailored to the individual patient, taking into account available drugs, efficacy versus side effects, contraindications, suitability, convenience, acceptability of route of administration, and costs. An overview of some of these factors is given in Table 53-1. In addition, treatment should be selected based on the overall severity of the patient’s disease. The patient with occasional mild migraine has different treatment needs than the patient with frequent and disabling migraine. Finally, treatment also should be tailored to the individual attack, taking into account severity, duration, and whether treatment is taken at the beginning of an attack or whether a full-blown attack is to be treated as when an attack is fully developed on awakening.

As shown in Table 53-1, the availability of drugs differs considerably. Whereas aspirin is available worldwide, this is not the case for the triptans. The authors’ opinions on efficacy and occurrence of side effects for the current drugs for treatment of migraine attacks are indicated in Table 53-1. The variability of reporting results in different controlled clinical trials for older drugs such as ergotamine and nonsteroidal anti-inflammatory drugs (NSAIDs; see Chapters 49 and 50) makes it impossible to compare these results with the results reported for the triptans in recent years in controlled clinical trials (see Chapter 51). Relatively few controlled clinical trials, eight with sumatriptan, two with zolmitriptan, one with rizatriptan, and one with eletriptan (see Chapter 51), have compared standard treatment with a triptan, and we will probably never have a definite scientific foundation for the rating of efficacy and side effects as given in Table 1.

Sumatriptan given as a subcutaneous injection has therapeutic gain (proportion of patients responding to active drug minus proportion of patients responding to placebo) of 50% after 1 hour in controlled clinical trials (for results with the triptans, see Chapter 51) and is rated as the most efficacious. Oral, intranasal, and rectal sumatriptan are less effective than subcutaneous sumatriptan, with therapeutic gains of approximately 30% after 2 hours, and similar results are reported for oral zolmitriptan, oral rizatriptan, oral almotriptan, and oral eletriptan. Oral naratriptan in the low dose chosen for clinical use has a therapeutic gain of approximately 20% after 2 hours. Frovatriptan has a therapeutic gain of 20%. Oral sumatriptan, oral rizatriptan, and oral eletriptan was found to be superior to oral ergotamine. Oral sumatriptan was somewhat more effective than aspirin plus metoclopramide in one trial and comparable with this combination in another trial. Intranasal and subcutaneous sumatriptan were both superior to intranasal dihydroer-gotamine, whereas rectal sumatriptan was inferior to rectal ergotamine plus caffeine in one trial. Subcutaneous sumatriptan was superior to subcutaneous dihydroergotamine for the first 2 hours, but the two drugs were comparable at later time points.

Speed of onset is highly valued by patients (2,5), and subcutaneous sumatriptan has an onset of action after 10 minutes, intranasal sumatriptan and zolmitriptan after 15 minutes, and 50 to 100 mg sumatriptan, 10 mg rizatriptan, 12.5 mg almotriptan, and 40 mg eletriptan after 30 minutes. It should be noted that, apart from subcutaneous sumatriptan, this early effect of the triptans is of relatively small magnitude. Thus, if a quick and clinically significant effect is needed, subcutaneous sumatriptan is
probably the best alternative. Because of to their pharmacodynamic properties, ergot alkaloids are generally more slowly acting drugs than the triptans (see Chapter 50).