What are the recommended abortive medications for acute migraine attacks?

Recommended Abortive Medications for Acute Migraine Attacks

For acute migraine attacks, NSAIDs (such as ibuprofen 400-600 mg, naproxen sodium 500-550 mg, or aspirin 800-1000 mg) are recommended as first-line treatment for mild to moderate attacks, while triptans are recommended as first-line therapy for moderate to severe attacks. 1

Treatment Algorithm Based on Migraine Severity

First-Line Options:

Mild to Moderate Migraine:

• NSAIDs:
  • Ibuprofen 400-600 mg
  • Naproxen sodium 500-550 mg
  • Aspirin 800-1000 mg 1

Moderate to Severe Migraine:

• Triptans:
  • Sumatriptan: 50 mg orally for most patients; 6 mg subcutaneously for severe attacks or those with significant nausea/vomiting 1, 2
  • Rizatriptan: 10 mg orally (for adolescents ≥40kg); maximum daily dose 200 mg/24 hours 1
  • Eletriptan: Shows highest treatment effect among triptans for pain-free response at 2 hours (68% probability of being most effective) 3

Second-Line Options:

• Antiemetics (especially when nausea/vomiting is prominent) 4, 1
• Ergot alkaloids (e.g., ergotamine, dihydroergotamine) 4, 5, 6

Third-Line Options:

• Ditans (lasmiditan) or gepants (ubrogepant, rimegepant) when triptans fail or are contraindicated 1, 6

Route of Administration Considerations

• For patients with early nausea/vomiting: Select non-oral routes 4

  • Subcutaneous sumatriptan (6 mg) provides most rapid and effective pain relief (59% pain-free at 2 hours vs. 15% with placebo; NNT 2.3) 2
  • Intranasal triptans (sumatriptan 20 mg; NNT 3.5) 2
  • Rectal sumatriptan (25 mg; NNT 2.4) 2

• For early treatment: Taking medication when pain is mild is more effective than waiting until pain becomes moderate or severe 2, 7

Important Considerations and Precautions

• Medication overuse prevention: To prevent medication overuse headache, limit:

  • Triptans: No more than 9 days per month
  • NSAIDs: No more than 15 days per month
  • OTC medications: No more than 14 days per month 1

• Triptan contraindications: Avoid in patients with:

  • Heart problems or history of heart disease
  • Stroke or blood circulation problems
  • Uncontrolled hypertension
  • Hemiplegic or basilar migraines 8

• Serotonin syndrome risk: Caution when combining triptans with SSRIs or SNRIs 8

• Avoid opioids and butalbital-containing medications unless other options have failed 6

Treatment of Associated Symptoms

• For nausea and vomiting: Add antiemetics even if patient is not actively vomiting 4
• Antiemetics should be considered for the aversive and disabling symptoms of nausea itself 4

Patient Education and Monitoring

• Encourage tracking of headache frequency, severity, duration, disability, response to treatment, and adverse effects using a headache diary 1
• Help patients identify and avoid migraine triggers 1
• Evaluate for preventive therapy if:
  • 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
  • Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura, migrainous infarction) 4, 1

The evidence clearly supports a stratified approach to migraine treatment, with NSAIDs for mild-moderate attacks and triptans for moderate-severe attacks. Among triptans, eletriptan has demonstrated superior efficacy, while subcutaneous sumatriptan provides the most rapid relief, especially important for patients with significant nausea or vomiting.