What are the recommended abortive medications for acute migraine attacks?

Recommended Abortive Medications for Acute Migraine Attacks

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy for acute migraine attacks, followed by migraine-specific agents (triptans, DHE) when NSAIDs fail to provide relief. 1

Step-by-Step Approach to Abortive Migraine Treatment

First-Line Therapy: NSAIDs

• Specific recommended NSAIDs:
  • Aspirin (650-1,000 mg every 4-6 hours)
  • Ibuprofen (400-800 mg every 6 hours)
  • Naproxen sodium (275-550 mg every 2-6 hours)
  • Combination of acetaminophen + aspirin + caffeine 1

Important note: Acetaminophen alone is ineffective for migraine treatment and should not be used as monotherapy. 1

Second-Line Therapy: Migraine-Specific Agents

When NSAIDs fail to provide adequate relief, use:

Triptans (Serotonin 1B/1D Agonists)

• Proven effective oral triptans:
  • Sumatriptan (oral, subcutaneous, intranasal)
  • Rizatriptan
  • Zolmitriptan
  • Naratriptan 1, 2

Subcutaneous sumatriptan has the most rapid onset of action, while oral naratriptan has a slower onset. 1

Ergot Derivatives

• Dihydroergotamine (DHE) nasal spray has good evidence for efficacy 1
• Ergotamine tartrate with caffeine can be used to abort or prevent vascular headaches 3

Special Considerations for Route of Administration

For patients with significant nausea or vomiting:

• Use non-oral routes of administration 1
• Options include:
  • Subcutaneous or intranasal sumatriptan
  • Intranasal DHE
  • Consider adding an antiemetic (such as metoclopramide) 1

Treatment Algorithm Based on Headache Severity

For Mild to Moderate Attacks:

1. Start with NSAIDs
2. If ineffective, move to triptans or DHE
3. Consider combination analgesics containing caffeine

For Moderate to Severe Attacks:

1. Use migraine-specific medications (triptans or DHE) as first-line
2. Consider combination therapy with antiemetics if nausea is present
3. For severe attacks unresponsive to above treatments, consider rescue medication 1

Important Cautions and Contraindications

• Triptans are contraindicated in patients with:

  • Risk for heart disease
  • Basilar or hemiplegic migraine
  • Uncontrolled hypertension 1

• Medication overuse risk:

  • Limit acute therapy to no more than twice per week
  • Consider preventive therapy if acute medications are needed more frequently 1, 4

• Avoid or strictly limit:

  • Opioids
  • Butalbital-containing compounds
  • These medications should be reserved only when other medications cannot be used due to risk of medication overuse headache and progression to chronic migraine 1, 4

Rescue Therapy

For severe attacks that don't respond to first- and second-line treatments, a self-administered rescue medication may be appropriate. This allows patients to achieve relief without requiring emergency department visits. 1

Early treatment during the mild pain phase provides significantly better outcomes than treating established attacks with moderate or severe pain intensity. 2

By following this structured approach to abortive migraine treatment, clinicians can effectively manage acute migraine attacks while minimizing the risk of medication overuse headache and optimizing patient outcomes in terms of reduced morbidity and improved quality of life.