What is the step therapy approach for abortive migraine treatment?

Abortive Migraine Step Therapy

For mild to moderate migraine attacks, start with oral NSAIDs (ibuprofen 400-800 mg, naproxen sodium 275-550 mg) or aspirin-acetaminophen-caffeine combination; for moderate to severe migraines or those failing NSAIDs, escalate to triptans as first-line therapy. 1

Step 1: Mild to Moderate Migraine

Initial therapy should prioritize:

• Aspirin-acetaminophen-caffeine combination (strong recommendation with number needed to treat of 9 for pain freedom at 2 hours) 1
• NSAIDs as monotherapy: Ibuprofen 400-800 mg, naproxen sodium 275-550 mg, or aspirin 650-1,000 mg 1
• Isometheptene combinations (isometheptene-acetaminophen-dichloralphenazone) for milder attacks 1

Critical caveat: Acetaminophen alone is NOT recommended for migraine—it must be combined with aspirin and caffeine to be effective 1

Step 2: Moderate to Severe Migraine or NSAID Failures

Escalate to migraine-specific agents:

• Triptans (first-line for this severity): Sumatriptan, rizatriptan, naratriptan, zolmitriptan, eletriptan, almotriptan 1

  • Rizatriptan achieves 33% pain freedom at 2 hours in adults 2
  • Contraindicated in: Vascular disease, uncontrolled hypertension, hemiplegic migraine 3, 4

• Gepants (newer option): Ubrogepant or rimegepant with number needed to treat of 13 for pain freedom at 2 hours 1

• Dihydroergotamine (DHE) for selected patients 1

  • Warning: Requires cardiovascular screening in patients with CAD risk factors; contraindicated with potent CYP3A4 inhibitors 3

• Ergotamine derivatives (less preferred due to side effect profile) 1

Step 3: Migraine with Nausea/Vomiting

Use non-oral routes of administration:

• Intranasal or subcutaneous triptans 1, 4
• Intranasal DHE 1
• Parenteral ketorolac 60 mg IM 1

Add antiemetic adjuncts:

• Metoclopramide 10 mg IV or oral (improves gastric motility and provides synergistic analgesia) 1
• Prochlorperazine 25 mg oral or suppository (can relieve headache pain directly) 1

Step 4: Severe Refractory Migraine

For attacks not responding to above treatments:

• Greater occipital nerve block (weak recommendation for abortive use) 1
• Rescue medications: Self-administered options to avoid emergency department visits 1
• Lasmiditan (5-HT1F agonist with robust efficacy but driving restrictions; number needed to harm of 4 for adverse effects) 1

Emergency department options:

• Intravenous antiemetics with or without IV DHE 4
• Dexamethasone as adjunct to prevent short-term recurrence 4

Critical Medications to AVOID or Limit

Strongly discouraged for routine use:

• Opioids (meperidine, butorphanol): Risk of dependency, rebound headaches, and loss of efficacy 1, 5, 4
• Butalbital-containing analgesics: Same concerns as opioids 1, 5
• Acetaminophen monotherapy: Ineffective for migraine 1

Monitor closely if used: Limit opioids to 50-150 mg meperidine IM/IV or butorphanol 1 mg intranasal spray (maximum 2 days/week) only when all other options exhausted 1

Treatment Timing and Frequency Principles

Administer medication as early as possible after symptom onset to maximize efficacy 1, 4

Avoid medication overuse headache:

• NSAIDs: Limit to <15 days/month 5
• Triptans: Limit to <10 days/month 5
• Monitor all abortive medications for overuse patterns 1

Special Population: Pregnancy

First-line: Acetaminophen 1,000 mg (safest option) 5

Second-line: Ibuprofen (second trimester ONLY) 5

Avoid: Ergotamine derivatives, DHE, topiramate, valproate, gepants (insufficient safety data) 5, 3

Sumatriptan: May be used sporadically under strict specialist supervision when other treatments fail 5

Adjunctive Strategies

Enhance treatment success with:

• Caffeine as adjunct (improves analgesic efficacy) 1
• Sleep induction for selected patients 1
• Hydration, regular meals, consistent sleep patterns 5
• Trigger identification and avoidance 5