What are the differences between abortive and prophylactic treatments for migraines?

Abortive vs. Prophylactic Migraine Treatments

Abortive treatments stop individual migraine attacks as they occur, while prophylactic treatments are taken regularly to prevent migraines from developing in the first place. 1

Abortive (Acute) Treatments

Abortive treatments are designed to stop migraine attacks once they've begun:

First-Line Options

• Triptans (e.g., sumatriptan, rizatriptan, zolmitriptan)

  • Most effective when taken early while pain is still mild 1
  • Should be used for moderate to severe attacks in a stratified care approach 1
  • Limitations: No more than 9 days per month to prevent medication overuse headache 1
  • Contraindicated in patients with CAD, Prinzmetal's angina, or history of stroke 2

• NSAIDs (e.g., ibuprofen 400-600mg, naproxen sodium 500-550mg)

  • Effective for mild to moderate attacks 1
  • Limitations: No more than 15 days per month 1

• Combination therapy (triptan plus NSAID or acetaminophen)

  • Should be initiated as soon as possible after headache onset 1
  • More effective than monotherapy for many patients

Second/Third-Line Options

• Ditans (lasmiditan) or Gepants (ubrogepant, rimegepant)
  • For patients who don't respond to or cannot tolerate triptans 1

Rescue Medications

• Opioids or butalbital-containing compounds
  • For use when other treatments fail 3
  • Allow relief without emergency department visits
  • Risk of dependency and medication overuse headache

Prophylactic (Preventive) Treatments

Prophylactic treatments are taken regularly to reduce frequency, duration, and severity of attacks:

Indications for Prophylaxis

Prophylactic treatment should be initiated when:

• Patient experiences ≥2 migraine attacks per month with disability lasting ≥3 days 3, 1
• Acute treatments are contraindicated or ineffective 1
• Patient uses abortive medications more than twice weekly 1
• Patient has uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 3

First-Line Prophylactic Options

• Beta-blockers

  • Propranolol (80-240 mg/day) and timolol (20-30 mg/day) have strongest evidence 3, 1
  • Metoprolol, nadolol, and atenolol also effective 3
  • Avoid in patients with asthma, depression, or who require physical activity 4

• Anticonvulsants

  • Topiramate: Only agent proven effective specifically for chronic migraine in randomized controlled trials 3
  • Valproate: Effective but contraindicated in women of childbearing potential 1, 5

• Antidepressants

  • Amitriptyline: Particularly effective for patients with comorbid depression or mixed migraine/tension headache 3

• CGRP Monoclonal Antibodies

  • Erenumab, fremanezumab, galcanezumab, eptinezumab
  • Strongly recommended with high-quality evidence 1
  • Newer options with fewer side effects than traditional preventives

Other Prophylactic Options

• Candesartan
• Flunarizine
• OnabotulinumtoxinA (Botox): Only FDA-approved therapy specifically for chronic migraine 3

Key Differences Between Abortive and Prophylactic Treatments

Aspect	Abortive Treatment	Prophylactic Treatment
Purpose	Stops individual attacks	Prevents attacks from occurring
Timing	Taken during migraine attack	Taken regularly regardless of attacks
Frequency	As needed	Daily or according to schedule
Duration	Short-term use	Long-term use (typically 6-12 months before tapering) [1]
Evaluation	Immediate relief of symptoms	Reduction in frequency/severity assessed after 2-3 months [1]
Medication classes	Triptans, NSAIDs, combination analgesics	Beta-blockers, anticonvulsants, antidepressants, CGRP antibodies

Common Pitfalls to Avoid

1. Medication Overuse Headache

   • Using acute medications (triptans, NSAIDs, combination analgesics) too frequently can lead to medication overuse headache 1, 2
   • Limit triptans to ≤9 days/month and NSAIDs to ≤15 days/month 1

2. Inadequate Trial Period for Prophylaxis

   • Prophylactic medications require 2-3 months to demonstrate efficacy 1
   • Don't abandon treatment too early

3. Failure to Address Comorbidities

   • Select prophylactic medications that can address comorbid conditions (e.g., amitriptyline for depression, beta-blockers for hypertension) 6

4. Overlooking Non-Pharmacological Approaches

   • Relaxation techniques, cognitive behavioral therapy, and regular exercise can complement pharmacological treatments 1
   • Biofeedback and acupuncture have evidence supporting their use 1

5. Not Considering Contraindications

   • Triptans contraindicated in cardiovascular disease 2
   • Valproate contraindicated in women of childbearing potential 5

By understanding the differences between abortive and prophylactic treatments and selecting the appropriate approach based on migraine frequency, severity, and patient characteristics, clinicians can significantly improve outcomes and quality of life for migraine sufferers.