From the Guidelines
Abortive therapy for migraines should start with first-line treatments including NSAIDs like ibuprofen (400-600mg) or naproxen (500-550mg) for mild to moderate migraines, as recommended by 1 and 1. For moderate to severe migraines, triptans are the gold standard, with options including sumatriptan (50-100mg oral, 6mg subcutaneous, or 20mg nasal spray), rizatriptan (10mg), or zolmitriptan (2.5-5mg), as supported by 1 and 1. These medications work by constricting blood vessels and blocking pain pathways in the brain. It is essential to take triptans at the first sign of migraine for best results. For nausea, adding an antiemetic like metoclopramide (10mg) or ondansetron (4-8mg) is recommended, as noted in 1. Newer options include gepants (rimegepant, ubrogepant) and ditans (lasmiditan) for those who can't take triptans due to cardiovascular concerns. Some key points to consider in abortive therapy for migraines include:
- Using a nonoral route of administration for patients whose migraines present early with nausea or vomiting as a significant component of the symptom complex, as suggested by 1 and 1.
- Limiting the use of abortive medications to 2-3 days per week to prevent medication overuse headaches, as advised by 1 and 1.
- Considering preventive therapy if experiencing frequent migraines, as recommended by 1 and 1. Overall, the goal of abortive therapy is to stop migraine attacks once they've begun, and the choice of treatment should be based on the severity of the migraine, the presence of nausea or vomiting, and the patient's medical history and preferences, as emphasized by 1, 1, and 1.
From the FDA Drug Label
Sumatriptan tablets, USP are a serotonin (5-HT1B/1D) receptor agonist (triptan) indicated for acute treatment of migraine with or without aura in adults. Rizatriptan benzoate is a 5-HT1 agonist indicated for the acute treatment of migraine attacks with or without aura in adults.
Abortive Therapy for Migraine:
- Sumatriptan and rizatriptan are both used as abortive therapies for migraine attacks.
- The dosage of sumatriptan is a single dose of 25 mg, 50 mg, or 100 mg tablet, with a maximum dose in a 24-hour period of 200 mg 2.
- Rizatriptan benzoate should be administered as needed, with a maximum of 30 mg per dose and no more than 30 mg in a 24-hour period, although the exact dosage is not specified in the provided text.
- Key Considerations:
- Use only if a clear diagnosis of migraine headache has been established.
- Not indicated for the prophylactic therapy of migraine attacks or the treatment of cluster headache.
- Contraindications include history of coronary artery disease, Wolff-Parkinson-White syndrome, history of stroke or transient ischemic attack, and uncontrolled hypertension, among others 2 3.
From the Research
Abortive Therapy for Migraine
- Abortive medications for migraine include triptans, ergot alkaloids, and calcitonin gene-related peptide (CGRP) receptor antagonists, as well as supplemental caffeine and antiemetics 4.
- The choice of abortive medication depends on the severity of the migraine, the presence of aura, and the patient's medical history and comorbidities 5.
- Triptans, such as sumatriptan, are effective for acute migraine treatment, with a therapeutic gain of 32% for oral sumatriptan 100mg 6.
- Combining triptans with nonsteroidal anti-inflammatory drugs (NSAIDs) may provide better efficacy for acute migraine treatment, with a fixed combination of sumatriptan and naproxen sodium offering improved 2-hour and 24-hour benefits over monotherapy 7.
- Initial abortive treatments for migraine headache should be stratified by choosing the optimal medication for the patient, taking into account the severity of pain, significant disability, and associated features such as nausea or vomiting 8.
- Medications such as neuroleptics may be used to treat nausea and vomiting, and rescue medication should be provided for occasional failure of usual treatment to avoid further disability or emergency room visits 8.
- It is essential to avoid medication overuse by matching treatment to patient needs, as repetitive and escalating medication use can lead to transformation of migraine into chronic daily headache with analgesic-dependent rebound 8.