What is the best treatment approach for abortive migraine in a patient with a history of frequent or severe migraine episodes, considering potential contraindications such as cardiovascular disease or pregnancy?

Abortive Migraine Treatment

First-Line Treatment Based on Attack Severity

For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) or the combination of aspirin 1000 mg + acetaminophen 1000 mg + caffeine, taken as early as possible when pain is still mild. 1, 2 For moderate to severe attacks or when NSAIDs fail, escalate immediately to triptans, with the combination of sumatriptan 50-100 mg PLUS naproxen 500 mg providing superior efficacy compared to either agent alone. 2

Stratified Treatment Algorithm

Mild to Moderate Attacks:

• First choice: Naproxen 500-825 mg or ibuprofen 400-800 mg at onset 1, 2
• Alternative: Aspirin 1000 mg + acetaminophen 1000 mg + caffeine (combination superior to acetaminophen alone) 1, 2
• Administer as early as possible during the attack to maximize efficacy 1

Moderate to Severe Attacks:

• First choice: Oral sumatriptan 50-100 mg PLUS naproxen 500 mg (130 more patients per 1000 achieve sustained relief at 48 hours versus monotherapy) 2
• Alternative triptans: Eletriptan 40-80 mg (highest probability of pain-free response at 68%), rizatriptan 10 mg, or zolmitriptan 2.5-5 mg 3
• Oral sumatriptan 50 mg provides pain-free response in 28% at 2 hours (NNT 6.1) versus 11% with placebo 4
• Oral sumatriptan 100 mg provides pain-free response in 32% at 2 hours (NNT 4.7) 4

Severe Attacks with Nausea/Vomiting (requiring non-oral route):

• First choice: Subcutaneous sumatriptan 6 mg (59% pain-free at 2 hours, NNT 2.3, onset within 15 minutes) 5, 6
• Alternative: Intranasal sumatriptan 20 mg (NNT 3.5 for headache relief at 2 hours) 5
• Add metoclopramide 10 mg IV or prochlorperazine 10 mg IV for nausea and synergistic analgesia 1, 2

Critical Frequency Limitation

Limit ALL acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which occurs with ≥10 days/month use of triptans or ≥15 days/month use of NSAIDs. 7, 2 If requiring acute treatment more frequently, initiate preventive therapy immediately. 2

Cardiovascular Contraindications

Triptans are absolutely contraindicated in patients with:

• Ischemic heart disease, prior myocardial infarction, or coronary artery vasospasm (Prinzmetal's angina) 8, 9
• Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders 8, 9
• History of stroke or transient ischemic attack 8, 9
• Peripheral vascular disease or ischemic bowel disease 9
• Uncontrolled hypertension 8, 9

For triptan-naive patients with multiple cardiovascular risk factors (age >40, diabetes, hypertension, smoking, obesity, strong family history of CAD), perform cardiovascular evaluation before prescribing triptans and consider administering the first dose in a medically supervised setting with ECG monitoring. 8

Alternative for patients with cardiovascular contraindications:

• IV ketorolac 30 mg PLUS IV metoclopramide 10 mg (provides rapid relief without cardiovascular risk) 2
• Dihydroergotamine (DHE) intranasal or IV (good efficacy evidence, but contraindicated in uncontrolled hypertension and peripheral vascular disease) 2

Pregnancy-Specific Treatment

For pregnant patients, acetaminophen 1000 mg is first-line acute treatment due to its relatively safe profile. 7 NSAIDs (ibuprofen) may be used ONLY during the second trimester. 7 Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail, with most safety data relating to sumatriptan specifically. 7

Absolutely avoid in pregnancy:

• Ergotamine derivatives and dihydroergotamine (oxytocic properties, can harm fetus) 7
• Opioids and butalbital-containing medications (risks of dependency, rebound headaches, and potential fetal harm) 7
• NSAIDs in first and third trimesters 7

For nausea in pregnancy:

• Metoclopramide 10 mg (oral or IV) is safe and effective, particularly in second and third trimesters 7
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain 7

Adjunctive Antiemetic Therapy

Add antiemetics 20-30 minutes before analgesics for synergistic benefit when nausea is present:

• Metoclopramide 10 mg (oral or IV) - provides direct analgesic effects beyond antiemetic properties 1, 2
• Prochlorperazine 10 mg (oral, IV, or 25 mg suppository) - relieves both nausea and headache pain 1, 2

Medications to Absolutely Avoid

Never use opioids (meperidine, hydromorphone, oxycodone) or butalbital-containing compounds for routine migraine treatment - they lead to dependency, medication-overuse headache, eventual loss of efficacy, and do not address migraine pathophysiology. 1, 7, 2 Reserve opioids only for rare situations when all other treatments are contraindicated AND the risk for abuse has been thoroughly addressed. 2

Common Pitfalls

• Treating too late: Efficacy decreases significantly when treatment is delayed until pain is moderate or severe rather than treating early when pain is mild 1, 4
• Underdosing: Sumatriptan 100 mg is significantly more effective than 50 mg for pain-free and sustained pain-free outcomes 4
• Not combining therapies: Triptan + NSAID combination provides superior efficacy versus monotherapy 2
• Missing medication-overuse headache: Increasing headache frequency despite treatment suggests MOH rather than treatment failure 2