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New Migraine Treatment Guidelines Announced

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The American College of Physicians (ACP) has just announced new guidelines for the treatment of migraine, which will interest doctors and specialists in the USA and around the world.

Headquarters of the American College of Physicians
Adapted from image by AhlqACP2024

The guidelines are specifically for “acute” migraine, that is, an episodic migraine attack.

These kinds of recommendations do not, of course, replace your personal interactions with your doctor, who knows your condition and your medical history. However, announcements like this do help us to gauge which treatments might be worth “trying first”, or what might work for a wide variety of patients.

After a survey of the current scientific studies, the ACP has these two recommendations:

  1. “ACP recommends that clinicians add a triptan to a nonsteroidal anti-inflammatory drug to treat moderate to severe acute episodic migraine headache in outpatient settings for nonpregnant adults who do not respond adequately to a nonsteroidal anti-inflammatory drug (strong recommendation; moderate-certainty evidence).”
  2. “ACP suggests that clinicians add a triptan to acetaminophen to treat moderate to severe acute episodic migraine headache in outpatient settings for nonpregnant adults who do not respond adequately to acetaminophen (conditional recommendation; low-certainty evidence).”

It’s somewhat surprising that acetaminophen (paracetamol) is still such a strong recommendation. But note that the second item doesn’t have the strong evidence behind it that the first does.

Attention has largely gone away from triptans with the introduction of CGRP related medications for migraine. However, triptans have a strong track record. Guidelines like these are not likely to include newer medications simply because they can’t have the same long-term evidence behind them.

Remember that this advice may not be the best for you. But it may be worth a try, especially if you haven’t tried it before. If your doctor has tried increasing your dose of acetaminophen or an NSAID (still at a safe level), and you’re not experiencing relief, it may be time to add a triptan.

The ACP did suggest that other medications be tried if these don’t work.

Another important recommendation was to never put the full focus on a “pill”. There’s no doubt that medication is not saving us. The ACP adds:

Highlight the importance of lifestyle modifications with patients, including staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, engaging in regular physical activity (preferably moderate to intense aerobic exercise), managing stress with relaxation techniques or mindfulness practices, and, where applicable, pursuing weight loss for those who are overweight or obese. Also, explore modifiable migraine triggers or contributing factors during a detailed history.

Pharmacologic Treatments of Acute Episodic Migraine Headache in Outpatient Settings

It’s worth noting that some of these items are far more powerful than today’s medications in the long term.

To read more, especially if you’re a specialist, doctor or patient, go straight to the full report here.

For an article with a summary of the recommendations, see Updated migraine treatment guidelines ‘a long time coming’.

“Older” Migraine Meds on Trial: What Works?

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Late last year a new study analyzed almost 4.7 million migraine attacks and the medications that patients took. According to those patients, which abortive medications actually worked?

The data was collected from patients’ responses on a smartphone app between 2014 and 2020 (which is why newer medications like gepants and ditans were not included in the study). Dosage was also not taken into consideration. Finally, the “baseline” was ibuprofun. In other words, which medications worked better than (or not as well as) ibuprofen?

However, as you can see, the sample size was huge. So which medications, according to patients, really fought back against an individual migraine attack?

It shouldn’t surprise too many that the migraine-targeting meds worked best:

  • Triptans (e.g. eletriptan, sumatriptan, zolmitriptan) were at the top of the list, working well 5x more often than ibuprofen.
  • Ergots (dihydroergotamine and ergotamine) were 3x more effective than ibuprofen
  • Anti-emetics (anti-nausea medications) were 2.5x more effective
  • Next came opioids, and NSAIDs (not including ibuprofen)

This is not to say that ibuprofen isn’t effective. It was still effective 42% of the time. And it roundly beat acetaminophen (paracetamol), which was effective 37% of the time.

But other similar NSAIDs other than ibuprofen may be worth trying – especially ketorolac, which came out as working 62% of the time, significantly more than its cousin ibuprofen.

Since triptans topped the list, which triptans tended to work the best? Well, it was the ones listed above, but not in that order:

  • eletriptan
  • zolmitriptan
  • sumatriptan

They were all considered effective over 70% of the time – and remember, triptans very much depend on the person, and also how they’re taken.

There’s no doubt that these “older” medications, even ibuprofen, are still helping a lot of people. Lists like this won’t necessarily tell you what will work for you. However, they do give you a place to start.

Your doctor will be able to take more of your personal medical history into consideration when recommending a medication. And there are also risks and side effects to consider, which also vary from person to person.

But if you’re a candidate for a triptan, one of the top three is probably going to be high on your doctor’s list. Tylenol, on the other hand, might be best left on the drugstore shelf, until you’ve tried some better options for migraine.

For the actual study abstract, you can go to Simultaneous Comparisons of 25 Acute Migraine Medications Based on 10 Million Users’ Self-Reported Records From a Smartphone Application.

For another more detailed analysis, check out Certain Migraine Medications May Be More Effective Than Ibuprofen.

A Natural Alternative to Sumatriptan? (Your Questions)

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Is there a good natural alternative to sumatriptan?

First, an apology – I’ve been negligent in answering your questions. So today I’m going to tackle one from Vicki in the USA.

Vicki finds that sumatriptan helps fight her migraine attacks. But she’s wondering if there’s a “natural alternative” to sumatriptan that she can use when she doesn’t have any medication available.

It’s a great question, but not an easy one! For one thing, triptan medications such as sumatriptan don’t seem to act the same in every person. And sometimes even small differences (such as the differences between a generic and a brand name medication, or different “delivery methods” – tablet, nasal spray, etc.) can make a difference in how well it works. Also, triptans may help with various symptoms (nausea, pain, sensitivity to light).

So you’re probably not going to find a precise alternative that does the exact same thing in your body.

Another reason why the question is difficult is that sumatriptan, as an older and much-studied medication, is often compared with other treatments. Some of these studies are high quality, others not. But the short story is that there are actually a lot of alternatives. Basically, most of the good alternative treatments that you’ve heard about are probably worth a try.

It may surprise many people that there are excellent, often well-studied alternatives to medications. Many people still assume that a “natural alternative” is going to be inferior. But that may not be the case at all.

So, to get back to the original question, here are some possible alternatives that you may want to try. But, as with medications, it will be trial and error, and you may need a combination of some of the treatments listed.

  • Water and salt – Staying hydrated is a great way to avoid migraine. But you may find that you can lesson the symptoms of an attack with some water and a salty snack. If you feel that you’ve eaten something that is triggering the attack, drinking more water may help lesson the trigger effect.
  • Ginger Supplement – This is one of those studies I was telling you about. In a study published in 2014, researchers found that a 250mg dose of ginger was comparable (in some ways better) than a 50mg dose of sumatriptan. Ginger has been used for pain and nausea in other conditions besides migraine.
  • Heat and Cold – Experimenting with heat and cold (ice and heat packs) has long been a helpful migraine treatment, but as with anything it seems to work differently depending on the person and the migraine attack.
  • MigreLief-Now – A combination supplement specifically designed to fight migraine when the attack is starting.
  • “Starve and Sink” – This method is completely counter-intuitive, but it’s becoming more well known thanks to the work of Dr. Josh Turknett. You can read more here: How To End A Migraine Without A Pill (starve and sink, part 1), and then part 2 here.

A few more things to consider. First, here’s a brief list of “natural remedy” ideas that may help.

Second, it’s important to consider overall lifestyle changes and possibly supplements that may help prevent migraine. I’m thinking about things like magnesium, cutting down on sugar (part 1 and part 2), and proper exercise.

Finally, there are other medications that you may be able to have on hand to stop an attack, and you may be surprised how effective they are (if taken very occasionally). For example, the humble aspirin and ibuprofen. Ketorolac is another example of a simple anti-inflammatory that has been compared to sumitriptan.

Have you found a natural supplement that has helped fight a migraine attack in the place of sumatriptan? Leave a comment, and let’s help Vicki by keeping the conversation going.

Why is Cluster Headache still so often Misdiagnosed?

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Why is cluster headache still so often misdiagnosed? Why do patients have to wait so long before they get proper treatment?

Misdiagnosis leading to the wrong treatment!

The folks over at The Conversation decided to send out a medical sociologist to see what doctors actually knew about cluster.

Their findings were perhaps not surprising. Many doctors still do not really have a clear idea of what cluster headache is. This ranged from doctors who didn’t really know what it was at all, to those who confused it with “cluster migraine”.

In spite of their lack of knowledge, or maybe we should say because of it, doctors were generally not referring patients with cluster headache to neurologists.

Even when cluster headache was diagnosed, patients were still not given the most recommended treatments. The Conversation gives this example:

For example, the injectable triptans were often not prescribed because of their high cost. Some GPs instead prescribed cheaper oral triptans. But these are not effective for cluster headache patients. Many interviewed clinicians were not aware of the prescription policies for oxygen, which is an effect treatment for cluster headache.

Cluster headache is more than ‘just a headache’ – but this excruciating condition is often misdiagnosed

Before we are too quick to blame doctors, we need to remember that cluster is quite rare. However, it is an important category of headache, and so this informal study may reflect not only on cluster headache, but headaches conditions in general, which are not well understood. In other words, this is not in a rare category, but in the very common category of headache disorders.

Today there are excellent tools for diagnosing types of headaches and finding the most evidence-based treatments. Doctors need to take the initiative to get basic training in headache treatment, which will give them the tools they need to diagnose quickly and get the patient the treatment they need.

To read the full article, go here: Cluster headache is more than ‘just a headache’ – but this excruciating condition is often misdiagnosed

An Update on AXS-07 (upcoming migraine medication)

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A new study has come out on AXS-07, a new abortive combination medication. With all the talk about injections, many patients will be glad to see a new “pill” coming down the pipeline!

You can find out more about AXS-07 here. In short, it’s a new formulation of meloxicam/rizatriptan. The latest news comes from the completion of a phase 3 trial.

The quick summary that’s promoting AXS-07 is that it has been shown to “prevent pain progression”. So what does that mean?

For many in the trial, AXS-07 did lead to “pain freedom” between 2 and 24 hours, a common measurement when it comes to pain medication. But these numbers, although significant, weren’t unusually high, although some patients did find they were pain-free as quickly as in 30 minutes.

So the even better news is that almost 3/4 of patients in the trial found that their migraine attack didn’t go beyond “mild” when they used AXS-07. The same percentage went back to “normal functioning” within 24 hours.

The other good news – no serious side effects, and very few experienced the most common side effects (such as dizziness, fatigue, or paresthesia (eg “pins and needles” feeling on the skin).

For more information, see:

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The articles on Headache and Migraine News are © 2004-2026 J. Cottrill.
Every effort is made to ensure the accuracy of each article, and to point you to further sources of information. However, this site is for informational purposes only and should never replace a visit to your doctor.