What medications are available for migraine treatment and medical abortion?

Available Medications for Migraine Abortion

For acute migraine attacks, first-line therapy should be nonsteroidal anti-inflammatory drugs (NSAIDs), with triptans reserved for moderate to severe attacks or when NSAIDs fail. 1, 2

First-Line Medications for Migraine

NSAIDs

• Ibuprofen: 400-800 mg every 6 hours (maximum 2.4g daily)
• Naproxen sodium: 275-550 mg every 2-6 hours (maximum 1.5g daily)
• Aspirin: 650-1000 mg every 4-6 hours (maximum 4g daily)
• Combination therapy: Acetaminophen plus aspirin plus caffeine (e.g., Excedrin Migraine)

NSAIDs have the most consistent evidence for efficacy in mild to moderate migraine attacks 1. They should be limited to no more than 15 days per month to avoid medication overuse headache 2.

Second-Line Medications (Migraine-Specific)

Triptans

When NSAIDs are insufficient or for moderate to severe attacks, triptans are recommended 1, 2:

1. Sumatriptan:

   • Oral: 50-100 mg (most effective dose is 100 mg) 3
   • Subcutaneous: 6 mg (most rapid relief) 4
   • Intranasal: 20 mg
   • Rectal: 25 mg

2. Other oral triptans:

   • Rizatriptan: 10 mg (5 mg if on propranolol)
   • Zolmitriptan: 2.5-5 mg
   • Naratriptan: 1-2.5 mg
   • Almotriptan: 12.5 mg
   • Frovatriptan: 2.5 mg

Subcutaneous sumatriptan provides the fastest and most effective relief, with pain reduced from moderate/severe to none in 59% of patients within 2 hours compared to 15% with placebo 4. However, it also has more adverse effects than other routes.

Important considerations for triptans:

• Contraindications: Cardiovascular conditions, uncontrolled hypertension, history of stroke/TIA, or Wolff-Parkinson-White syndrome 2, 5
• Limitations: No more than 9 days per month to avoid medication overuse headache 2
• Common side effects: Chest/throat tightness, dizziness, fatigue 5, 6

Ergotamine Derivatives

• Dihydroergotamine (DHE): Available as nasal spray or injectable forms
• Ergotamine with caffeine (Cafergot): Oral or rectal suppository

These have more limited use due to potential for medication-overuse headaches, ergot poisoning, and negative effects on migraine prophylactic medications 1.

Alternative Routes of Administration

For patients with significant nausea/vomiting or rapid onset of migraine:

• Non-oral options: Subcutaneous sumatriptan, intranasal sumatriptan/zolmitriptan, rectal sumatriptan, orally disintegrating tablets (rizatriptan, zolmitriptan) 7
• Consider antiemetics: For nausea/vomiting as part of the migraine complex 1

Preventive Therapy

Consider preventive therapy for patients with:

• Two or more attacks per month with disability lasting 3+ days
• Contraindication to or failure of acute treatments
• Use of abortive medication more than twice per week
• Uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 1

First-line preventive options:

• Beta-blockers: Propranolol (80-240 mg/day), timolol (20-30 mg/day)
• Antidepressants: Amitriptyline (30-150 mg/day)
• Anticonvulsants: Divalproex sodium (500-1500 mg/day), sodium valproate (800-1500 mg/day), topiramate
• CGRP antagonists: Erenumab, fremanezumab, galcanezumab
• Angiotensin receptor blockers: Candesartan, telmisartan 2

Important Clinical Pearls

1. Early treatment: Taking medication at the onset of migraine when pain is mild is more effective than waiting until pain is moderate or severe 3.

2. Medication overuse headache: Limit acute therapy to no more than twice per week and sumatriptan to no more than 9 days per month 2.

3. Combination therapy: Using a triptan with an NSAID or acetaminophen may provide better efficacy than monotherapy for resistant cases 2.

4. Route selection: Consider non-oral routes for patients with significant nausea/vomiting or those needing rapid relief 1, 7.

5. Avoid opioids and butalbital-containing medications due to risk of dependence and medication overuse headache 2.