Migraine is a highly disabling episodic disease caused by neurovascular dysfunction. Patients typically experience moderate to severe, recurrent headaches accompanied by symptoms such as nausea, vomiting, photophobia, or fear of sound. Migraine not only affects the quality of life of patients, but may also be accompanied by 21 comorbidities such as sleep disorders, anxiety, and depression.

As a common chronic neurovascular disease, migraines bring enormous pain and burden to patients. It not only affects the patient's work and daily life, but may also lead to serious psychological and social dysfunction. Therefore, timely and effective acute phase treatment is crucial for improving the quality of life of patients.

 The accompanying symptoms that most troubled the patient within 2 hours (i.e. nausea, vomiting, photophobia, or fear of sound) disappeared;

 Pain relief after 2 hours, from moderate to severe pain to mild or painless

 At least 2 out of 3 episodes are effective;

 The headache disappears within 2 hours of treatment, and there is no recurrence of headache or further use of analgesic drugs within 24 or 48 hours.

Medication

Principles of drug selection:

The medication used in the acute phase of migraine is divided into non-specific drugs (such as acetaminophen, nonsteroidal anti-inflammatory drugs, and caffeine containing compound preparations) and specific drugs (such as triptans, zepam, Ditan, and ergotamine drugs). The preferred treatment for acute migraine is nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen. If the treatment is ineffective, only partially effective, or intolerable after taking the recommended dosage and timing of medication, or if there are contraindications, specific drugs such as triptans, gepants, and ditans can be chosen for treatment.

Apply acute phase medications as early as possible during headache attacks, but avoid using drugs containing opioids or barbiturates as much as possible. Start preventive treatment as early as possible to reduce the frequency of migraine attacks.

During the acute phase of migraine, medication should be avoided from overuse. If patients continue to use medication excessively despite prophylactic treatment, the acute phase and prophylactic treatment plan should be adjusted. Acute phase drugs and their frequency of use are usually:
① NSAIDs, acetaminophen, and lamivudine should not exceed an average of 2-3 days per week and 10 days per month;
② Triptolide drugs should be administered no more than 2 days per week and no more than 8 days per month on average;
③ Compound preparations containing caffeine should not exceed an average of 2 days per week and 8 days per month. Due to strong drug dependence and significant adverse reactions, the use of ergots, opioids, and barbiturates is not recommended. If necessary, the frequency of use should be controlled at no more than 4 days per month for ergots; Containing opioid drugs for no more than 8 days per month; Barbital containing drugs should not exceed 5 days per month.

Non pharmacological therapy

Self management of headaches is very important, including lifestyle adjustments and avoiding triggering factors. At present, there are many non pharmacological therapies that can also be used for the treatment of migraine in the acute phase. These therapies can be used in combination with drugs or applied alone when patients are intolerant to conventional drug therapy or have drug contraindications. It mainly includes neural regulation therapy such as remote nerve regulation, transcranial magnetic stimulation, vagus nerve stimulation, trigeminal nerve stimulation, occipital trigeminal nerve combined stimulation, as well as acupuncture, hypnosis, biofeedback, and cognitive-behavioral therapy.

Treatment of pregnant and lactating patients

The preferred treatment for acute migraine during pregnancy and lactation is non pharmacological therapy. If drug therapy is not effective, acetaminophen is the preferred medication for pregnancy, but it is recommended to minimize the frequency of use as much as possible, especially in late pregnancy. There is limited research on the use of triptans during pregnancy, and population-based and registry based studies have shown that the use of triptans does not increase the incidence of birth defects. Among them, sumatriptan has the lowest incidence of birth defects and is recommended as a second-line treatment. NSAIDs such as ibuprofen, aspirin, and naproxen can only be used in mid pregnancy. Due to the crucial role of prostaglandins in embryo implantation, NSAIDs are not recommended for women planning to conceive. If accompanied by nausea or vomiting, or insufficient pain relief, treatment with metoclopramide can be combined. Peripheral nerve block (lidocaine, ropivacaine) is safe and feasible.
The preferred medication for lactation is acetaminophen, ibuprofen, and diclofenac. Due to the high degree of protein binding and low concentration in breast milk of triptan drugs, they can be used as a secondary choice for NSAIDs with poor efficacy. Shumaputan is the most commonly used drug. Since the drugs used for nerve block do not enter breast milk in large quantities, peripheral nerve block can be performed. Until new evidence emerges, monoclonal antibodies and receptor antagonists related to CGRP should be avoided during lactation.

Acetaminophen can be used as a first-line treatment for patients with stroke, coronary heart disease, or difficult to control hypertension. Ramidian does not increase the risk of cardiovascular disease and can be used as a second-line treatment for acute migraine in patients with concomitant cardiovascular and cerebrovascular diseases.

Jipan drugs have no direct vasoconstrictive effect and can only inhibit CGRP induced vasodilation. Currently, there are no literature reports on acute cardiovascular and cerebrovascular disease events caused by Jipan drugs, which can be used as a second-line treatment for patients with concomitant cardiovascular and cerebrovascular diseases in the acute phase. However, due to the vasodilatory effect of CGRP, which may provide protection against ischemic cardiovascular and cerebrovascular diseases, its blockade may worsen ischemic cardiovascular and cerebrovascular diseases. Until further evidence is available, patients at high risk of vascular accidents or those who have already experienced vascular damage, Raynaud's phenomenon, or symptoms of small vessel disease should be cautious with use of zepam drugs.

NSAIDs can be used for the acute phase treatment of patients with cardiovascular and cerebrovascular diseases, but the frequency of use should be minimized to avoid bleeding and thrombotic events. In addition, long-term or excessive use of NSAIDs can increase the risk of venous thrombosis and atrial fibrillation. Some NSAIDs, such as ibuprofen and naproxen, may inhibit the antiplatelet effect of aspirin and increase the risk of ischemic events after use. Therefore, patients who have recently experienced stroke or cardiovascular events should avoid using them. Patients with cardiovascular and cerebrovascular diseases usually undergo long-term antithrombotic therapy. If NSAIDs are needed for acute migraine attacks, it is recommended to use proton pump inhibitors to reduce gastrointestinal bleeding.

At present, triptan drugs are still prohibited for patients with cardiovascular and cerebrovascular diseases. Ergotamine or dihydroergotamine can sustainably constrict blood vessels, causing elevated blood pressure, coronary artery spasm, and myocardial ischemia. It is contraindicated for patients with cardiovascular disease.

Compared with adult patients, children (6-11 years old, including 11 years old) and adolescents (12-17 years old, including 17 years old) have more common and shorter duration bilateral headaches. For patients with short duration headaches, bed rest alone can alleviate them. Firstly, non pharmacological treatment is recommended. If non pharmacological treatment is ineffective, pharmacological treatment should be initiated. The evaluation criteria for treatment are the same as those for adults. Acetaminophen (15mg/kg; maximum daily dose 60 mg/kg) and ibuprofen (10mg/kg; maximum daily dose 30mg/kg) are recommended as first-line medications for the treatment of acute phase in children and adolescents. Aspirin is not recommended for patients under the age of 16 as it may induce Reye's syndrome. Based on the currently available triptan drugs in China, it is recommended to use 5mg of zolmitriptan nasal spray for adolescents with poor efficacy of acetaminophen or ibuprofen, and 5mg of rizatriptan (body weight<40kg; 10mg, body weight ≥ 40kg) for children and adolescents aged 6 years and above with poor efficacy of acetaminophen or ibuprofen.

Acetaminophen is the preferred drug, but the dosage should be adjusted appropriately based on the weight and liver function of elderly patients. The compound preparation of acetaminophen combined with caffeine can also be used, but attention should be paid to the risk of drug overuse. If acetaminophen is not effective, NSAIDs can be considered as a secondary option, but attention should be paid to the risk of gastrointestinal bleeding and liver and kidney damage. If there are contraindications or poor efficacy of acetaminophen or NSAIDs, triptan drugs, Ditan drugs, and Jipan drugs can also be used as options. Triton drugs should be used in patients with hypertension control and no cardiovascular or cerebrovascular diseases. When using lamivudine, potential central inhibition and the risk of falls due to dizziness should be informed. Jipan drugs are metabolized by liver cytochrome P450 enzymes, and drug interactions should be taken into account. In terms of antiemetic agents, domperidone does not cross the blood-brain barrier, making it less likely to cause extrapyramidal adverse reactions and central symptoms such as dizziness and drowsiness. However, it is important to rule out drug contraindications. Metoclopramide is prone to extrapyramidal effects, as well as adverse reactions such as drowsiness and dizziness, and elderly people need to be closely monitored when using it.

The release of the "Guidelines for the Treatment of Acute Migraine in China (First Edition)" provides us with a comprehensive "first aid kit" for the treatment of acute migraine. Follow the guidelines to scientifically manage migraines, alleviate pain, and improve quality of life. If you or your family members are suffering from migraines, you may refer to this guide to seek professional medical assistance.