What are the recommended abortive medications for acute migraine attacks?

Recommended Abortive Medications for Acute Migraine Attacks

NSAIDs are first-line therapy for most mild to moderate migraine attacks, while triptans are recommended for moderate to severe attacks or when NSAIDs fail to provide relief. 1, 2

First-Line Treatment Options

For Mild to Moderate Attacks:

• NSAIDs with proven efficacy include aspirin, ibuprofen, naproxen sodium, and the combination of acetaminophen plus aspirin plus caffeine 3, 1
• Acetaminophen alone lacks sufficient evidence for efficacy in migraine treatment 3, 1
• Treatment should begin as early as possible during the attack to improve efficacy 2

For Moderate to Severe Attacks:

• Triptans (serotonin1B/1D agonists) are recommended as first-line therapy 1, 2
• Specific oral triptans with good evidence include:
  • Sumatriptan 4, 5
  • Naratriptan 3, 1
  • Rizatriptan 3, 6
  • Zolmitriptan 3, 1
  • Eletriptan (shown to have highest treatment effect in comparative studies) 7, 8

Route of Administration Considerations

• For patients with significant nausea or vomiting, non-oral routes should be selected: 3, 2

  • Subcutaneous sumatriptan provides the most rapid pain relief (59% pain-free at 2 hours vs 15% with placebo) 5
  • Intranasal sumatriptan or zolmitriptan 9, 5
  • Intranasal dihydroergotamine (DHE) 3, 2

• Add antiemetics (such as metoclopramide or prochlorperazine) to treat nausea, even if vomiting is not present 1, 2

Second-Line and Rescue Treatments

• If first-line treatments fail, consider: 2

  • Alternative triptan (if one triptan is ineffective, another may work) 8
  • Dihydroergotamine (DHE) nasal spray 3, 2
  • Antiemetics as monotherapy, particularly intravenous metoclopramide 2
  • Parenteral NSAIDs, such as ketorolac, for rapid onset 2

• For status migrainosus (prolonged, severe migraine):

  • Intravenous corticosteroids are recommended 1
  • Concurrent antiemetics to treat nausea and improve gastric motility 1

Important Cautions and Contraindications

• Triptans should not be given to patients with: 6, 7

  • Ischemic or vasospastic coronary artery disease
  • History of stroke or transient ischemic attack
  • Uncontrolled hypertension
  • Hemiplegic or basilar migraines

• Medication overuse headache can result from frequent use of acute medications (more than twice weekly) 2, 6, 7

  • This can lead to increasing headache frequency and potentially daily headaches
  • Particularly problematic with opioids and butalbital-containing compounds

• Serotonin syndrome risk increases when triptans are used with SSRIs, SNRIs, or MAO inhibitors 6, 7

  • Monitor for symptoms like mental status changes, autonomic instability, neuromuscular abnormalities, and gastrointestinal symptoms

Comparative Efficacy of Triptans

• Eletriptan consistently shows the highest treatment effect in comparative studies 8

  • 68% probability of being the most effective triptan for pain-free response at 2 hours
  • 54% probability for 24-hour sustained pain-free response

• Subcutaneous sumatriptan shows greater efficacy than oral routes, particularly within the first hour after administration 5

  • However, this comes with relatively higher levels of adverse events and financial cost

• Taking medication early, when pain is mild, provides significantly better pain relief than waiting until pain becomes moderate or severe 4, 5