Treating an Acute Attack of Migraine

An important skill to perfect is obtaining the most benefit possible from your migraine medication. This often requires a systematic approach to acute treatment.


Set a Goal for Acute Treatment.—A reasonable goal is to be free of migraine within 2 hours, with no return of migraine for at least 24 hours.This goal may not be achieved every time, but it provides a “gold standard” by which different medications objectively can be compared.


Recognize Migraine as a Process.—While headache and migraine are often considered synonymous, they are not. Migraine is always more than headache. Learning the non-headache symptoms associated with your migraine is essential to early recognition of an attack.

The headache-associated symptoms of a migraine attack are divided into 3 components: (1) symptoms occurring before the headache begins; (2) symptoms associated with the headache; (3) symptoms occurring after the headache resolves. Symptoms beginning before headache often predict that the migraine will progress and require treatment. The Table lists common pre-headache symptoms.

The Figure depicts different phases of a migraine attack. The ideal time to treat is in the shaded area of the Figure. Regardless of the medication you use, treating migraine at this point generally provides the best results. After treating a given migraine attack, use this diagram to assess where in the migraine process you treated and how you might improve your strategy next time.

Table.—Common Pre-Headache Symptoms

Mood changes

Fatigue Sensitivity to light, sound, or odors

Food cravings

Difficulty thinking


Muscle tension

Nasal stuffiness or drainage

Excessive yawning


Excessive energy

In scientific studies the percentage of people achieving pain-free status within 2 hours of treatment has been almost double for those treating early (when headache is mild in intensity) vs those treating when headache is moderate or severe.With successful early treatment headache also is less likely to return, and there are fewer side effects from the medication taken. Can you know that a mild/early headache will develop into a disabling migraine if early treatment is withheld? Yes. In one study, 93% of migraine sufferers who typically notice symptoms of migraine before headache could accurately predict a disabling migraine at the onset of the mild headache. This means that with practice and close observation, most people effectively can treat early, when the headache is mild, and not waste medication by treating headaches unlikely to develop into full-blown migraine.


Determine Which Migraines Need Treatment.—Often people with migraine consider themselves to have many different types of headache: tension, sinus, menstrual, etc. Most of the time,  however, all are migraine. Migraine is the great masquerader; migraine headache may be accompanied by muscle pain and spasm or nasal congestion. A migraine attack may resolve spontaneously at any point in its evolution, thus causing most afflicted people to have “little” and “big” headaches. For most, it makes sense to treat one headache disorder – migraine – rather than attempt to manage migraine as just one of their 3 or 4 different headache types. If there is doubt about your diagnosis, discuss it with your healthcare provider. Not all migraines require the same treatment, and not all migraines require medication. For example, if caught early, a migraine triggered by missing a meal may be treated simply by eating; if the migraine is more fully developed, however, then medication may be needed. It is useful to consider combining medication and non-medication treatments for migraine; for example, 15 minutes of rest after taking medication may make a positive difference in the outcome of treatment. Learning these headache management skills takes practice.


Observe Medication Use.—Monitor the use of your medications to ensure that you are not using them too frequently. A rule of thumb is to avoid exceeding use of a medication more than 2 days a week or 5 days a month. More frequent use should trigger a visit to your healthcare provider.


Understand a Migraine Attack.—Analyze migraine attacks that resist treatment. Common reasons for unsuccessful treatment are (1) the medication was used too late in the attack; (2) the formulation of the medication was not appropriate (eg, oral administration makes little sense if nausea and vomiting are prominent); (3) the dose of medication was too low; or (4) the medication itself is insufficient to the needs of the particular individual and needs to be changed.

Learning how to manage effectively is essential to controlling one’s migraine. The rewards are great for those who become adept at treating their migraines acutely.

Roger K. Cady, MD

Headache Care Center,

Springfield, MO, USA