What are alternative abortive treatments for a patient with migraines not relieved by Imatrex (sumatriptan)?

Alternative Abortive Treatments for Migraine Not Relieved by Sumatriptan

Try a different triptan first—failure of one triptan does not predict failure of others, and if all triptans fail after adequate trials (2-3 headache episodes each), escalate to newer CGRP antagonists (gepants) like ubrogepant or rimegepant. 1, 2

Immediate Next Steps: Try Alternative Triptans

Before abandoning the triptan class entirely, systematically trial different triptans, as pharmacological heterogeneity offers different efficacy profiles despite their similarities 1, 3:

• Rizatriptan 10 mg reaches peak concentration in 60-90 minutes, making it the fastest oral triptan 1, 2
• Eletriptan 40 mg or zolmitriptan 2.5-5 mg are reportedly more effective with fewer adverse reactions than sumatriptan 1, 2
• Naratriptan has the longest half-life, which may decrease recurrence headaches 1

Critical principle: Patients should try each medication for 2-3 headache episodes before abandoning that specific triptan 1

Consider Route of Administration Change

If oral sumatriptan failed, switching routes can dramatically improve outcomes 2:

• Subcutaneous sumatriptan 6 mg provides the highest efficacy (70-82% response rate) with onset within 15 minutes, compared to only 50-67% response for oral formulations 1, 2, 4
• Intranasal sumatriptan (5-20 mg) or other nasal spray triptans are particularly useful when significant nausea or vomiting is present 1, 2
• Rizatriptan as absorbable wafer (Maxalt MLT) offers non-oral administration without injection 1

First-Line Non-Triptan Alternatives: CGRP Antagonists (Gepants)

When triptans are contraindicated or ineffective after adequate trials, gepants are the primary oral alternative 2:

• Ubrogepant 50-100 mg or rimegepant have strong evidence-based efficacy for moderate to severe migraine 2
• Major advantage: No vasoconstriction, making them safe for patients with cardiovascular disease, uncontrolled hypertension, or cerebrovascular disease—common triptan contraindications 2
• Zavegepant is also available as an alternative 2

Second-Line Alternative: Ditans

• Lasmiditan (Reyvow) 50-200 mg is a 5-HT1F receptor agonist without vasoconstrictor activity, safe for patients with cardiovascular disease 2
• Critical warning: Patients must not drive or operate machinery for at least 8 hours after taking lasmiditan due to CNS effects (dizziness, vertigo, somnolence, fatigue) 2

Combination Therapy Strategy

Combining a triptan with an NSAID provides superior efficacy compared to either agent alone 2:

• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg has high-certainty evidence, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 2
• Add an antiemetic (metoclopramide 10 mg or prochlorperazine 25 mg) 20-30 minutes before the triptan for synergistic analgesia 2

Parenteral Options for Severe Attacks

When oral medications consistently fail 2:

• IV metoclopramide 10 mg plus IV ketorolac 30 mg provides rapid pain relief with minimal rebound headache risk 2
• Dihydroergotamine (DHE) intranasal or IV has good evidence for efficacy as monotherapy 1, 2
• Prochlorperazine 10 mg IV effectively relieves headache pain and is comparable to metoclopramide 2

Critical Frequency Limitation to Prevent Medication-Overuse Headache

Limit ALL acute migraine medications to no more than 2 days per week (10 days per month for triptans, 15 days per month for NSAIDs) 2, 5:

• Medication-overuse headache can result from frequent use, leading to daily headaches 2
• If requiring acute treatment more than twice weekly, initiate preventive therapy immediately 2

Medications to Absolutely Avoid

Do not use opioids or butalbital-containing compounds—they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time 2, 6

When to Initiate Preventive Therapy

If headaches continue despite optimized acute therapy, or if using acute medications more than 2 days per week, preventive therapy is indicated 2:

• First-line preventives: Propranolol 80-240 mg/day, topiramate, or candesartan 2, 7
• Preventive therapy requires 2-3 months to assess efficacy for oral agents 2, 7
• Preventive therapy reduces attack frequency and can restore responsiveness to acute treatments 2