An effective acute migraine management plan does more than terminate attacks—it also prevents progression. Early intervention, stratified care, and structured rescue strategies can reduce central sensitization, prevent progression, and lower the risk of developing chronic migraine.

One of the biggest risk factors for developing chronic migraine is having more frequent attacks. So, I always tell my patients that having an effective migraine “attack plan” is the best way to prevent the transformation of episodic migraine to chronic migraine. An effective attack plan is therefore a preventive treatment plan because it will reduce the risk of developing more frequent and severe attacks in the future.

It is also important for patients to understand that when a migraine attack starts and is in its mild phases, there are certain changes occurring in the brain that lead to symptoms. Once the pain reaches the moderate to severe phase, additional neurophysiologic changes occur called “central sensitization,” which makes it more difficult for as-needed treatment options to be effective.

Many of our first-line migraine-specific treatments, such as triptan medications, are more effective when the pain is mild and/or the migraine attack has just started, so it is very important that patients initiate their acute treatment plan as soon as they feel the attack starting. This is an approach called “stratified care,” which is in opposition to step care. Step care involves starting with a less targeted over-the-counter medication and then escalating therapy every 2 hours as needed. What happens in this situation is that every 2 hours, the migraine attack is becoming more severe and disabling, more central sensitization is occurring, and the migraine is becoming more difficult to treat, and, eventually, a higher risk of transformation to chronic migraine develops.

Alternatively, in a stratified care approach, we start with migraine-specific therapy to treat the migraine attack as soon as possible when it is first coming on to reduce the likelihood that the attack will progress to status migrainosus. If the patient’s pain is mild, they can use a triptan alone. If the migraine attack has very rapidly escalated to moderate to severe pain, this is a sign that there is central sensitization. While a triptan medication does not reverse central sensitization, an NSAID does. So, I would recommend for patients to use their migraine-specific medication plus an effective NSAID. If they have nausea, they can also use promethazine, prochlorperazine, or metoclopramide. The goal of acute therapy is for the patient to be back to their “normal self” within 2 hours. If the patient is still not feeling back to normal after this period, I will usually instruct them to re-administer the triptan and to add an NSAID and an antiemetic. If they are using ubrogepant, they can do the same thing. With rimegepant, that cannot be repeated within 1 day, so we will develop a plan that includes an NSAID plus or minus an antiemetic, plus or minus a triptan.

If the second dose of medications is still ineffective, this is when we activate the “rescue plan,” which can vary depending on the patient. For some patients, the rescue plan may be a short course of oral corticosteroids. For other patients, we may use injectable medications, such as intramuscular ketorolac, along with promethazine or prochlorperazine if there is associated vomiting. Patients with persistent vomiting are at risk for dehydration, and if they are still vomiting by day 2 of their migraine attack, I instruct them to call our clinic so that we can send them to an infusion center, where we will initiate 1 to 3 days of acute intravenous treatment.

This usually includes intravenous fluids for rehydration, 1 to 2 grams of magnesium, ketorolac, and an antiemetic such as promethazine or prochlorperazine. This will usually stop the migraine attack from continuing to progress to status migrainosus.