What are the recommended abortive medications for migraines?

Recommended Abortive Medications for Migraines

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line therapy, followed by triptans for moderate to severe attacks or when NSAIDs fail. 1, 2, 3

First-Line Treatment Options

• NSAIDs with proven efficacy include aspirin, ibuprofen, naproxen sodium, and the combination of acetaminophen plus aspirin plus caffeine 1
• Acetaminophen alone lacks evidence for efficacy in migraine treatment 1
• For moderate to severe migraine attacks, triptans are recommended as first-line therapy 2, 3
• Triptans with good evidence for efficacy include:
  • Oral sumatriptan, naratriptan, rizatriptan, and zolmitriptan 1, 4
  • Subcutaneous sumatriptan 1, 4
  • Dihydroergotamine (DHE) nasal spray 1, 2

Treatment Algorithm Based on Migraine Severity

For Mild to Moderate Attacks:

• Start with NSAIDs (aspirin, ibuprofen, naproxen sodium) 1, 3
• If inadequate response within 2 hours, escalate to a triptan 1

For Moderate to Severe Attacks:

• Begin with a triptan (sumatriptan, rizatriptan, zolmitriptan, naratriptan) 2, 3
• Among triptans, sumatriptan subcutaneous injection, rizatriptan ODT, zolmitriptan ODT, and eletriptan tablets have shown the most favorable outcomes 4

For Attacks with Significant Nausea/Vomiting:

• Select a non-oral route of administration (subcutaneous, nasal spray) 1, 5
• Add an antiemetic to treat nausea, even if vomiting is not present 1

Second-Line Treatment Options

• Antiemetics (metoclopramide, prochlorperazine) are recommended for migraine with significant nausea 1, 5
• Ergot alkaloids (ergotamine, dihydroergotamine) can be used when triptans are contraindicated or ineffective 6, 3
• Newer agents such as gepants and ditans may be considered as second-line options when triptans are contraindicated, particularly in patients with cardiovascular risk factors 3

For Status Migrainosus (Prolonged, Severe Migraine)

• Systemic corticosteroids are the treatment of choice 2, 5
• Intravenous corticosteroids are the mainstay of treatment 5
• Antiemetics should be given concurrently to treat nausea and improve gastric motility 5
• Parenteral NSAIDs such as ketorolac can be effective due to rapid onset 5

Important Cautions and Contraindications

• Triptans are contraindicated in patients with:
  • Ischemic or vasospastic coronary artery disease 7
  • History of stroke or transient ischemic attack 7
  • Uncontrolled hypertension 7, 8
• Triptans should not be given during the migraine aura phase 8
• Triptans should not be combined with ergotamine or other vasoconstrictive substances 7, 8
• Avoid opioids and butalbital-containing medications unless other options have been ineffective 3
• Be vigilant for medication overuse headache with frequent use of acute migraine medications 7
• Monitor for serotonin syndrome when triptans are used with SSRIs, SNRIs, TCAs, or MAO inhibitors 7

Comparative Efficacy of Triptans

• Standard dose triptans provide 2-hour headache relief in 42-76% of patients 4
• Sustained freedom from pain at 24 hours is achieved in 18-33% of patients 4
• Triptans are generally more effective than ergots and equal or better than NSAIDs, ASA, and acetaminophen 4
• Combination therapy with triptans plus ASA or acetaminophen may provide slightly better outcomes than standard dose triptan tablets alone 4

Remember that approximately 40% of patients who initially respond to oral or subcutaneous sumatriptan may experience recurrence of their headache within 24 hours, which can be effectively treated with a further dose 8.