What are alternative abortive medications for migraine management in a patient who isn’t responding to sumatriptan (Imitrex)?

Alternative Abortive Medications for Migraine Management When Sumatriptan Fails

For patients who don't respond to sumatriptan, trying a different triptan should be the first alternative approach, as lack of response to one triptan does not predict lack of response to another. 1

Alternative Triptan Options

• Rizatriptan (Maxalt) - Consider as first alternative due to:

  • Faster onset of action (peak concentration in 60-90 minutes vs. 2-3 hours for most other triptans) 2
  • Higher efficacy rates compared to sumatriptan in comparative studies 3
  • Available in an absorbable wafer form (Maxalt MLT) which is beneficial for patients with nausea/vomiting 2
  • FDA-approved for acute treatment of migraine with or without aura 4

• Naratriptan (Amerge) - Consider for patients with frequent recurrence headaches:

  • Longest half-life among triptans, which may decrease chance of recurrence headaches 2
  • Good efficacy in treating migraines in patients who failed sumatriptan 1

• Zolmitriptan, Almotriptan, or Frovatriptan - Additional triptan options:

  • Almotriptan may be one of the most appropriate choices for patients who don't respond to sumatriptan 1
  • Frovatriptan and almotriptan reportedly have more rapid onset of action than sumatriptan 2

Non-Triptan Alternatives

• Dihydroergotamine (DHE) - Consider for severe migraines:

  • Available in parenteral preparations and as nasal spray 2
  • Good evidence for efficacy and safety as monotherapy for acute migraine attacks 5
  • More appropriate for treatment of severe migraines 2
  • Contraindicated with triptans, beta blockers, pregnancy, and several other conditions 2

• NSAIDs - Consider for mild to moderate attacks:

  • Recommended as first-line treatment for mild to moderate migraine attacks 5
  • Options include aspirin, ibuprofen, naproxen sodium, and ketorolac 5
  • IV ketorolac (30mg) is effective for severe migraine with minimal risk of rebound headache 5

• Antiemetics - Consider especially when nausea/vomiting present:

  • Metoclopramide (10 mg IV or oral) provides synergistic analgesia for migraine pain 5
  • Prochlorperazine (10 mg IV) effectively relieves headache pain 5

Important Clinical Considerations

• Try any medication for 2-3 headache episodes before abandoning that line of therapy 2
• Match the characteristics of the drug with the patient's needs and usual headache duration 2
• Consider non-oral routes of administration when significant nausea or vomiting is present 6
• Treat early during the mild pain phase for better outcomes 7

Contraindications and Cautions

• Avoid ergot alkaloids in pregnancy and with chronic use due to oxytocic properties and peripheral vasoconstriction 2
• Triptans are contraindicated in ischemic vascular conditions, vasospastic coronary disease, uncontrolled hypertension, or significant cardiovascular disease 2
• Avoid using triptans and ergot derivatives together 2
• Limit acute treatments to no more than twice weekly to prevent medication overuse headache 6

Treatment Algorithm

1. First attempt: Try a different triptan (rizatriptan recommended as first alternative)
2. If triptan alternatives fail: Consider DHE for severe migraines or NSAIDs for mild-moderate attacks
3. For patients with significant nausea/vomiting: Consider non-oral routes (intranasal, injectable) or add antiemetics
4. For severe, refractory attacks: Consider IV combination therapy with metoclopramide plus ketorolac