The current state of acute treatment for migraine in adults in the United States

Figures & data

Table 1. Acute treatments for migraine

Medication	Formulation	Estimated Cost (US Dollars) Generic/Branded
First-line treatments
Acetaminophen (Tylenol)	325 mg	$2/$10 for 30 tablets
NSAIDs
Aspirin	325 mg	$3/$3 for 30 tablets
Diclofenac potassium (Cambia)	50 mg	$19 for 60 tablets/$534 for 9 packets
Ibuprofen (Advil)	200 mg	$7/$10 for 100 tablets
Naproxen sodium (Anaprox)	500 mg	$3/$8 for 30 tablets
Triptans
Almotriptan (Axert)	12.5 mg	$108/$514 for 12 tablets
Eletriptan (Relpax)	40 mg	$27/$367 for 6 tablets
Frovatriptan (Frova)	2.5 mg	$100/$876 for 9 tablets
Naratriptan (Amerge)	2.5 mg	$20/$511 for 9 tablets
Rizatriptan (Maxalt)	10 mg	$13/$333 for 9 tablets
Sumatriptan (Imitrex)	100 mg	$12/$605 for 9 tablets
Zolmitriptan (Zomig)	5 mg	$26/$1,156 for 9 tablets
Ergotamines
Dihydroergotamine mesylate (D.H.E. 45), injectable	1 mg/mL	$48/$1,169 for 1 ampule
Dihydroergotamine mesylate (Migranal) nasal spray	4 mg/mL	$1,243/$3,779 for 8 vials
Combined regimens
Acetaminophen/aspirin/ Caffeine	Acetaminophen 250 mg/aspirin 250 mg/caffeine 65 mg	$5/$6 for 24 tablets
Sumatriptan/naproxen (Treximet)	Sumatriptan 85 mg/naproxen 500 mg	$132/$1056 for 9 tablets
Second-line treatments
Antiemetics
Chlorpromazine	25 mg	$37 for 30 tablets (generic only)
Metoclopramide (Reglan)	10 mg	$5/$113 for 30 tablets
Prochlorperazine	10 mg	$9 for 30 tablets (generic only)
Promethazine	25 mg	$10 for 30 tablets (generic only)
Novel Acute Treatments
Ubrogepant (Ubrelvy)	50 mg	$847 for 10 tablets (brand only)
Lasmiditan (REYVOW)	100 mg	$640 for 8 tablets (brand only)
Rimegepant (NURTEC ODT)	75 mg	$847 for 8 tablets (brand only)

Source for treatments is Marmura et al. 2015.

Prices listed on 16 April 2020 at www.cvs.com for over-the-counter medications, and goodrx.com for prescription medications.

Table 2. Efficacy of triptans for pain freedom at 2 hours

Triptan, standard dose	Pain Freedom at 2 Hours (%)
Almotriptan, 12.5 mg	25
Eletriptan, 40 mg	39
Frovatriptan, 2.5 mg	35
Naratriptan, 2.5 mg	18
Rizatriptan, 10 mg	37
Sumatriptan, 50 mg	28
Zolmitriptan, 2.5 mg	27

Proportions of study participants reporting pain freedom at 2 h is based on meta-analysis performed by Cameron et al., 2015.

Table 3. Potential adverse events of acute treatments for migraine

Medication	Most Common Adverse Events
Acetaminophen	Nausea, vomiting, headache, and insomnia
NSAIDs	NSAIDs have a black box warning regarding cardiovascular, and gastrointestinal risk
Aspirin	Gastrointestinal events including dyspepsia, hepatic enzyme elevation, hepatitis, and Reye’s Syndrome
Diclofenac	Gastrointestinal events including: abdominal pain, constipation, diarrhea, dyspepsia, flatulence, gross bleeding/perforation, heartburn, nausea, GI ulcers (gastric/duodenal), and vomiting Abnormal renal function, anemia, dizziness, edema, elevated liver enzymes, headaches, increased bleeding time, pruritus, rashes and tinnitus
Ibuprofen	Nausea, epigastric pain, heartburn, diarrhea, abdominal distress, nausea and vomiting, indigestion, constipation, abdominal cramps or pain, fullness of GI tract (bloating and flatulence)
Naproxen	Dyspepsia, abdominal pain, nausea, headache, rash, ecchymosis, and edema
Triptans
Almotriptan	Nausea, dry mouth, and paresthesia
Eletriptan	Asthenia, nausea, dizziness, and somnolence
Frovatriptan	Dizziness, headache (other than a migraine headache), paresthesia, dry mouth, dyspepsia, fatigue, feeling hot or cold, chest pain, skeletal pain, and flushing
Naratriptan	Paresthesias, nausea, dizziness, drowsiness, malaise/fatigue, throat/neck symptoms
Rizatriptan	Asthenia/fatigue, somnolence, pain/pressure sensation and dizziness
Sumatriptan	Paresthesia, warm/cold sensation, chest pain/tightness/pressure and/or heaviness, neck pain/pressure/tightness/heaviness, vertigo, malaise/fatigue
Zolmitriptan	Neck/throat/jaw pain/tightness/pressure, dizziness, paresthesia, asthenia, somnolence, warm/cold sensation, nausea, heaviness sensation, and dry mouth
Ergotamines
Dihydroergotamine mesylate	Rhinitis, nausea, altered sense of taste, application site reactions, dizziness, vomiting
Combined regimens
Acetaminophen/aspirin/caffeine	Nausea, vomiting, headache, insomnia Gastrointestinal events including dyspepsia, hepatic enzyme elevation, hepatitis, and Reye’s Syndrome Nervousness, irritability, sleeplessness, and, rapid heartbeat
Sumatriptan/naproxen	Dizziness, somnolence, paresthesia, nausea, dyspepsia, dry mouth, chest discomfort/chest pain, neck/throat/jaw, pain/tightness/pressure
Antiemetics
Chlorpromazine	Drowsiness, dizziness, dry mouth, blurred vision, fatigue, nausea, constipation, and trouble sleeping
Metoclopramide	Restlessness, drowsiness, fatigue, and lassitude
Prochlorperazine	Drowsiness, dizziness, amenorrhea, blurred vision, skin reactions, and hypotension
Promethazine	Drowsiness, dermatitis, photosensitivity, urticaria, dry mouth, asthma, nasal stuffiness, hyperexcitability, and abnormal movement
Serotonin (5-HT)1F receptor agonists
Lasmiditan	Dizziness, fatigue, paresthesia, and sedation
CGRP receptor antagonists
Rimegepant	Nausea and hypersensitivity reactions
Ubrogepant	Nausea, somnolence, and dry mouth

The presentation of the most common adverse events is based on the prescribing information for each product.

Table 4. Noninvasive neuromodulation devices approved in the US

Device	Technology	Approved Use
SpringTMS® by eNeura	Transcranial Magnetic Stimulation	Acute or prevention in adolescents (12 years or older) and adults
Cefaly® Acute by Cefaly Technology Cefaly® Prevent Cefaly® Dual	Transcranial Neural Stimulation	Acute in adults with migraine or prevention in adults with episodic migraine
gammaCore Sapphire™ by electroCore	Vagus Nerve Stimulation	Acute or prevention in adults with migraine
Nerivio™ by Theranica	Remote Electrical Neuromodulation	Acute treatment in adults with episodic migraine

This table is based on information gathered from the device manufacturers and the FDA at www.eneura.com, www.cefaly.us, www.gammacore.com, theranica.com/nerivio/, and www.fda.gov/medical-devices/510k-clearances.