New ACP guideline recommends combination therapy for acute episodic migraines

The American College of Physicians (ACP) has developed new recommendations for treatment of acute episodic migraines in nonpregnant adults in outpatient settings. ACP evaluated pharmacologic treatments known to be effective for migraine treatment using the best available comparative effectiveness evidence of benefits and harms, patients’ values and preferences, and economic evidence in order to prioritize the most effective treatments. The new guideline is published in Annals of Internal Medicine.

In its guideline, ACP makes two recommendations:

• 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.
• 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.

ACP also provides guidance to clinicians to consider counseling nonpregnant adults to begin treatment for acute migraine headache as soon as possible after its onset by utilizing combination therapy: a triptan with an NSAID or a triptan with acetaminophen.

Migraine is characterized by recurrent episodes of usually moderate to severe intensity headache lasting 4 to 72 hours with or without sensory disturbances, generally pulsating and often accompanied by nausea, vomiting, or aversion to light or sound. The condition remains underdiagnosed and undertreated.

ACP recently published a companion guideline, Prevention of Episodic Migraine Headache using Pharmacologic Treatments in Outpatient Settings, which addressed new recommendations for the prevention of episodic migraine in nonpregnant adults. In that guideline, ACP prioritized treatments based on economic and public and patient’s values and preferences evidence because the benefits and harms of evaluated treatments were balanced. However, for migraine treatment, ACP prioritized the combination of a triptan and an NSAID or acetaminophen because benefits outweighed the harms compared with other pharmacologic treatments.

Reference:

Amir Qaseem, Jeffrey A. Tice, Itziar Etxeandia-Ikobaltzeta, et al. Pharmacologic Treatments of Acute Episodic Migraine Headache in Outpatient Settings: A Clinical Guideline From the American College of Physicians. Ann Intern Med. [Epub 18 March 2025]. doi:10.7326/ANNALS-24-03095.