What is the recommended frequency for taking abortive medications like triptans (serotonin receptor agonists) for migraines?

Recommended Frequency for Taking Abortive Medications for Migraines

Abortive migraine medications such as triptans should be limited to no more than 9 days per month to prevent medication overuse headache. 1

Frequency Limitations for Abortive Medications

The American Academy of Neurology and American Headache Society provide clear guidelines on how frequently abortive medications can be used:

• Triptans (e.g., sumatriptan): No more than 9 days per month
• Over-the-counter medications (e.g., ibuprofen, Excedrin Migraine): No more than 14 days per month
• NSAIDs: No more than 15 days per month
• Gepants (e.g., Ubrelvy): No more than 8 days per month 1

For sumatriptan specifically, the FDA label states that "the safety of treating an average of more than 4 headaches in a 30-day period has not been established." 2

When to Consider Preventive Therapy

Patients should be evaluated for preventive therapy if they:

• Experience two or more migraine attacks per month with disability lasting 3 or more days
• Have contraindications to or failure of acute treatments
• Use abortive medication more than twice per week 1

This last point is particularly important as it indicates that using abortive medications more than 8 times per month should trigger consideration of preventive therapy.

Proper Dosing of Triptans

When using sumatriptan:

• Recommended doses: 25mg, 50mg, or 100mg
• If migraine hasn't resolved after 2 hours, a second dose may be administered
• Maximum daily dose: 200mg in a 24-hour period
• Doses should be separated by at least 2 hours 2

Common Pitfalls to Avoid

1. Medication overuse headache: Using abortive medications too frequently can lead to medication overuse headache, a secondary headache disorder that can be difficult to treat.

2. Inadequate dosing: Starting with too low a dose may result in inadequate relief. The FDA label notes that 50mg and 100mg doses may provide greater effect than 25mg, though 100mg may not be superior to 50mg. 2

3. Ignoring warning signs for preventive therapy: Patients using abortive medications more than twice weekly should be considered for preventive therapy rather than continuing to increase abortive use. 1

4. Delayed treatment: Abortive medications should be initiated as soon as possible after headache onset for maximum effectiveness. 1

Alternative Approaches

If patients are approaching the maximum recommended frequency for abortive medications:

• Consider first-line preventive medications: beta blockers, topiramate, candesartan, amitriptyline, or divalproex sodium 1
• For patients with frequent migraines, CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) are strongly recommended 1
• Implement non-pharmacological approaches: regular exercise, sleep hygiene, adequate hydration, trigger identification and avoidance, and relaxation techniques 1

By adhering to these frequency limitations and considering preventive therapy when appropriate, patients can effectively manage migraines while minimizing the risk of medication overuse headache.