What are the recommended abortive medications for acute migraine attacks?

Abortive Migraine Medication

First-Line Treatment: NSAIDs for Mild to Moderate Migraine

For most migraine sufferers with mild to moderate attacks, start with NSAIDs as first-line therapy. 1, 2, 3

• Specific NSAIDs with proven efficacy include aspirin, ibuprofen, naproxen sodium, and the combination of acetaminophen plus aspirin plus caffeine. 1, 2, 3
• Acetaminophen (paracetamol) alone lacks evidence for efficacy in migraine treatment and should only be used if NSAIDs cannot be tolerated. 1, 4
• Begin treatment as early as possible during the attack to improve efficacy. 2

Escalation to Triptans for Moderate to Severe Migraine

If NSAIDs fail to provide adequate relief within 2 hours, or if the migraine is moderate to severe at onset, escalate to a triptan. 1, 2, 3

Oral Triptans (Most Common Route)

• Effective oral triptans include sumatriptan, rizatriptan, naratriptan, and zolmitriptan. 1, 2, 3
• Oral sumatriptan 50 mg provides pain-free response in approximately 28% of patients at 2 hours (versus 11% with placebo), with an NNT of 6.1. 5
• Oral sumatriptan 100 mg is more effective than 50 mg, with an NNT of 4.7 for pain-free response at 2 hours. 5
• Triptans are most effective when taken early in the attack, when headache is still mild. 4, 5
• Do not use triptans during the aura phase of a migraine attack. 4

Non-Oral Routes for Nausea/Vomiting

Select a non-oral route of administration when significant nausea or vomiting is present early in the attack. 1, 2, 3

• Subcutaneous sumatriptan 6 mg is the most effective abortive treatment, providing pain-free response in 59% of patients at 2 hours (versus 15% with placebo), with an NNT of 2.3. 6
• Subcutaneous administration provides more rapid pain relief than other routes. 6
• Intranasal sumatriptan 20 mg has an NNT of 4.7 for pain-free response at 2 hours. 7
• Intranasal dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy. 1, 2

Combination Therapy: Triptan Plus NSAID

For patients who respond inadequately to either NSAIDs or triptans alone, combine a triptan with an NSAID. 4

• Sumatriptan 85 mg plus naproxen 500 mg provides superior efficacy compared to either agent alone, with an NNT of 3.1 for pain-free response at 2 hours when treating mild pain. 8
• The combination is significantly more effective when treating early (mild pain) versus waiting until pain is moderate or severe. 8

Adjunctive Treatment for Nausea

Add an antiemetic to treat nausea, even if vomiting is not present, as nausea itself is one of the most disabling symptoms of migraine. 1, 2, 3

• Metoclopramide 10 mg IV provides synergistic analgesia in addition to treating nausea. 2
• Prochlorperazine 10 mg IV is comparable to metoclopramide in efficacy. 2

Critical Safety Considerations

Cardiovascular Contraindications

Do not use triptans in patients with ischemic heart disease, coronary artery vasospasm, uncontrolled hypertension, or history of stroke. 9, 10

• Triptans can cause coronary artery vasospasm, myocardial infarction, and serious cardiac arrhythmias. 9, 10
• Patients with multiple cardiovascular risk factors (age >40 in men, postmenopausal women, diabetes, hypertension, smoking, obesity, family history of CAD) require cardiovascular evaluation before first triptan use. 9

Medication Overuse Headache

Limit acute medication use to no more than 2 days per week to prevent medication overuse headache. 1, 2, 10

• Overuse of acute migraine drugs (≥10 days per month) leads to exacerbation of headache frequency and severity. 10
• This applies to all abortive medications including NSAIDs, triptans, opioids, and combination products. 1, 10

Serotonin Syndrome Risk

Avoid combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors when possible due to risk of serotonin syndrome. 9, 10

• Symptoms include mental status changes, autonomic instability, neuromuscular aberrations, and GI symptoms. 10
• Discontinue triptan immediately if serotonin syndrome is suspected. 10

Rescue Therapy and Treatment Failures

If one triptan fails, try a different triptan before abandoning the class entirely. 4

• Different triptans may provide relief even when others have failed. 4
• For rapid peak headache intensity or when all oral triptans fail, subcutaneous sumatriptan 6 mg is most effective. 4, 6
• Opioids should only be reserved as last-line agents when other evidence-based treatments have failed or are contraindicated, sedation is not a concern, and abuse risk has been addressed. 1, 2

Treatment Algorithm Summary

1. Mild to moderate migraine: Start with NSAIDs (aspirin, ibuprofen, naproxen sodium, or acetaminophen+aspirin+caffeine) 1, 3
2. If inadequate response in 2 hours: Add or switch to oral triptan 3, 4
3. Moderate to severe migraine at onset: Start with oral triptan or triptan+NSAID combination 3, 4, 8
4. Early nausea/vomiting: Use subcutaneous or intranasal triptan + antiemetic 1, 2, 3
5. Treatment failure: Try different triptan or subcutaneous sumatriptan 4, 6
6. Always treat early when pain is mild for best outcomes 8, 5