Acute Abortive Migraine Therapy

Abortive migraine therapy should be used as soon as possible after symptom development for maximum benefit; if abortive therapy is unsuccessful or used more than twice weekly, consider adding prophylactic therapy. Patients with nausea and vomiting may require nonoral medication. For all medications, consider patient comorbidities and contraindications.

Primary Category
Headache & Pain
P-Category
Secondary Category
S-Category

Introduction

  • The abortive (symptomatic) therapy ranges from simple analgesics to migraine-specific drugs.
  • Abortive treatment is more effective if it is given early in the course of the headache.
  • A large single dose works better than repeated smaller doses.
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If abortive therapy is unsuccessful or used more than twice weekly, consider adding prophylactic therapy.

Pharmacological Approach

  • Directed mainly by the:
    • Severity of the attacks,
    • Presence of associated nausea and vomiting,
    • Treatment setting (outpatient or medical care facility),
    • Patient-specific factors such as vascular risk factors and drug preferences.

Mild to Moderate Attacks

  • Attacks not associated with nausea or vomiting;
    • Simple analgesics (NSAIDs, acetaminophen)
    • Combination analgesics (NSAIDs with Triptans)
  • Attacks associated with nausea or vomiting;
    • Simple analgesic or combination
    • Intramuscular, oral disintegrating tablets or intranasal antiemetics

Moderate to Severe Attacks

  • Attacks not associated with nausea or vomiting;
    • Oral Triptans or Combination (NSAIDs with Triptans)
    • Calcitonin Gene-Related Peptide antagonist
    • Ditans
  • Attacks associated with nausea or vomiting;
    • Nonoral migraine-specific
      • Subcutaneous sumatriptan
      • Nasal sumatriptan
      • Parenteral dihydroergotamine
      • Sphenopalatine ganglion block
      • Occipital nerve block

Status Migrainosus

  • Intravenous Fluids
  • Parenteral Medication:
    • NSAIDs; Ketorolac
    • Dopamine receptor blocker
    • Valproate
    • Dihydroergotamine; following the Raskin protocol
  • Parenteral Dexamethasone is often used to prevent attack relapses

Figure 1: Management of Acute Headache

 
notion image
 

Table 1: First-line therapies

Therapy
Drugs and their dose
Major Adverse Effects
Considerations
Combination Analgesics
Acetaminophen 250 mg/ Aspirin 250 mg: 1 to 2 tablets every 6 hourly. Do not exceed 8 tablets per day.
See individual medications
Available over the counter
NSAIDS
Ibuprofen: 200 to 800 mg orally every 6 to 8 hours. Do not exceed 2.4 g per day. Naproxen: 250 to 500 mg orally every 12 hours. Do not exceed 1 g per day.
Heartburn, gastric bleeding, ulcers, rebound headaches, renal toxicity, can exacerbate heart failure and hypertension.
Available over the counter. Cannot be used in third trimester of pregnancy
Triptans
Almotriptan: 6.25 to 12.5 mg orally. Repeated 2 hourly. Do not exceed 25 mg per day. Eletriptan: 20 to 40 mg orally. Repeated 2 hourly. Do not exceed 80 mg per day. Frovatriptan: 2.5 mg orally. Repeated 2 hourly. Do not exceed 7.5 mg per day. Naratriptan: 1 to 2.5 mg orally. Repeated 1-2 hourly. Do not exceed 5 mg per day. Rizatriptan: 5 to 10 mg orally. Repeated 2 hourly. Do not exceed 30 mg per day. Sumatriptan: Intranasal; 5 to 20 mg. Repeated 2 hourly. Do not exceed 40 mg per day. Oral; 25 to 100 mg. Repeated 2 hourly. Do not exceed 200 mg per day. Subcutaneous; 4 to 6 mg. Repeated 2 hourly. Do not exceed 12 mg per day. Zolmitriptan: Intranasal; 5 mg. Repeated 2 hourly. Do not exceed 10 mg per day. Oral disintegrating tablets; 2.5 mg. Repeated 2 hourly. Do not exceed 10 mg per day. Subcutaneous; 1.25 to 2.5 mg. Repeated 2 hourly. Do not exceed 10 mg per day.
Hypertension, vasospasm, chest pain, malaise, fatigue, rebound headache.
Avoid in patients with myocardial infarction, cerebrovascular accident, Prinzmetal angina, uncontrolled hypertension, or other vascular diseases, and in pregnant women. Serotonin syndrome reported on adjunct use with SSRIs.
Combination Triptans and NSAIDs
Sumatriptan 85mg/ Naproxen 500mg: 1 tablet at onset, can be repeated in 2 hours. Do not exceed 2 tablets per day.
See individual medications
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Table 2: Other effective therapies

Therapy
Drugs and their dose
Major adverse effects
Considerations
Antiemetics
Metoclopromide: 10 mg IV every 8 hours Prochlorperazine: 10 mg IV every 8 hours, not to exceed 40 mg per day Ondansetron: 4mg ODT
Dystonic reaction, parkinsonism with metoclopramide.
———
Steroids
Dexamethasone: 10 to 25 mg IV, one-time dose
Hyperglycemias, mood changes, insomnia: multiple adverse effects with long-term use
Use as adjunctive therapy only
Ergotamines
Dihydroergotamine: Intranasal; 1 spray in each nostril, repeat once after 15 minutes, do not exceed 4 sprays per attack, 6 sprays per day, 8 sprays per week. IV; 0.5 to 1 mg repeated 8 hours, or continuous IV infusion totalling 3 mg per 24 hours, not to exceed 3 mg per attack. Subcutaneous; 1 mg every hour, do not exceed 3 mg per day.
Nausea, rhinorrhea with intranasal use
IV dosing can be used in combination with 10 mg metoclopramide every 8 hours as needed for nausea.
Isometheptene
Acetaminophen 325mg/dichlorphenazone,100mg/isometheptene, 65mg: 1 to 2 capsules orally every 4 hours. Do not exceed 8 capsules per day
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Use with caution in patients with cardiovascular risk factors.
Local Anaesthetic
Lidocaine: Intranasal; 0.5 ml of topical lidocaine 4% solution dripped into nostril on the affected side over 30 seconds
Rare cardiac if absorbed systemically.
Symptoms may recur.

Further Reading

  • Recurrence of primary headache disorders after emergency department discharge: frequency and predictors of poor pain and functional outcomes. Ann Emerg Med 2008;52(6):696Y704. doi:10.1016/ j.annemergmed.2008.01.334.

Bibliography

  • Recurrence of primary headache disorders after emergency department discharge: frequency and predictors of poor pain and functional outcomes. Ann Emerg Med 2008;52(6):696Y704. doi:10.1016/ j.annemergmed.2008.01.334.
  • Gelfand, A. A., & Goadsby, P. J. (2012). A Neurologist’s Guide to Acute Migraine Therapy in the Emergency Room. The Neurohospitalist2(2), 51–59. https://doi.org/10.1177/1941874412439583
  • VanderPluym, J. H., Halker Singh, R. B., Urtecho, M., Morrow, A. S., Nayfeh, T., Torres Roldan, V. D., Farah, M. H., Hasan, B., Saadi, S., Shah, S., Abd-Rabu, R., Daraz, L., Prokop, L. J., Murad, M. H., & Wang, Z. (2021). Acute Treatments for Episodic Migraine in Adults. JAMA325(23), 2357. https://doi.org/10.1001/jama.2021.7939

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