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Migraine Abortive Treatment
Aka: Migraine Abortive Treatment, Migraine Abortive Management
- See Also
- Migraine Headache
- Migraine Headache Management
- Migraine Headache Management in Children
- Emergency Department Migraine Headache Care
- Migraine Medications in Pregnancy
- Migraine Medications in Breast Feeding
- Headache in Pregnancy
- Management: General Pointers
- Consider abortive agent sparing measures
- See Headache General Measures
- See Migraine Prophylaxis
- Establish Migraine Management Clinic Schedule
- Evaluate acute Headache regimen with standardized symptom score
- Migraine Treatment Optimization Questionnaire (M-TOQ)
- Lipton (2009) Cephalalgia 29(7):751-9 [PubMed]
- Serrano (2015) Headache 55(4):502-18 [PubMed]
- Migraine Assessment of Current Therapy (Migraine-ACT)
- Dowson (2004) Neurol Sci 25 Suppl 3:S276-8 +PMID:15549559 [PubMed]
- Kilminster (2006) Headache 46(4):553-62 [PubMed]
- Avoid use of abortive agents more than twice per week
- Frequent use results in Rebound Headache
- NSAIDs are unlikely to cause Rebound Headache
- Gastrointestinal motility drugs improve efficacy
- Metoclopramide (Reglan)
- Dose: 10 mg PO 20-30 minutes before pre-medication
- Extrapyramidal Side Effects
- Dystonic Reaction (especially in children)
- Antiemetic effect in addition to increased motility
- Antiemetics may be very useful in abortive treatment
- Alleviate Nausea associated with Headache
- Sedation to allow rest despite Headache
- Increases medication absorption (e.g. Reglan)
- Combined therapies may be helpful in refractory cases
- Aspirin and Metoclopramide
- Aspirin 975 mg PO (three 325 mg tablets)
- Metoclopramide (Reglan) 10 mg PO
- DHE and Vistaril Combination
- DHE-45 1 mg IM
- Vistaril 75 mg IM
- Management: Serotonin Agonists
- Triptans
- Sumatriptan (Imitrex)
- Rizatriptan (Maxalt)
- Zolmitriptan (Zomig)
- Naratriptan (Amerge)
- Ergotamines (do not use within 24 hours of Triptans)
- Dihydroergotamine (DHE-45)
- Ergotamine
- Management: Oral Analgesics
- General
- Beware Rebound Headaches with most Analgesics
- Analgesics with proven efficacy
- Excedrin Migraine (Acetaminophen, Aspirin, Caffeine)
- Aspirin 975 mg PO (with or without Metoclopramide)
- Midrin (Isometheptene, Dichloralphenazone, Tylenol)
- Dose: 2 stat at Headache onset
- Repeat 1 each hour prn
- Maximum: 5 pills per 12 hours, 20 pills per month
- Limit use to no more than 2 days per week
- Anaprox, Aleve (NaproxenSodium)
- Absorbed more rapidly than Naprosyn
- Initial Dose: 825 mg (Three 275 mg tablets)
- Repeat 220 to 550 mg every 3-4 hours
- Maximum: 1.5 grams per day (5 to 6 tablets per day)
- Analgesics to be avoided (low efficacy and higher risk)
- Cafergot (Ergotamine with Caffeine)
- Dose: 2 PO stat with Headache onset
- Repeat one tablet every half hour prn
- Maximum: 4 to 6 pills per day or 10 per week
- Fiorinal (ASA 325mg, Caffeine 40mg, Butalbital 50mg)
- Dose: 2 tablets at Headache onset
- Repeat one tablet every 4 to 6 hours prn
- Maximum: 5 pills per day or 15 per month
- Limit use to no more than 2 days per week
- Risk of Rebound Headaches with use more than 5 days per month
- Esgic or Fioricet (Tylenol, Caffeine, Butalbital)
- Same dosing recommendations and precautions as for Fiorinal
- Precaution: Pharmaceutical obfuscation alert
- Fioricet brand name capsules (Watson) as of 2014 will contain 300 mg Acetaminophen (at 4x the generic cost)
- Fioricet generic tablets will contain 325 mg Acetaminophen (making automatic substitution difficult)
- One more reason not to prescribe fioricet (other Migraine abortive agents are preferred)
- (2014) Presc Lett 21(3)
- Management: Parenteral Analgesics
- See Emergency Department Migraine Headache Care
- See Serotonin Agonists (Triptans) below
- See Opioids below (avoid if possible)
- Ketorolac (Toradol)
- Dose: 30-60 mg IM
- May repeat 15-30 mg q6h
- Do not exceed 5 consecutive days of use
- May supplement with rectal Antiemetic
- Management: Rectal Analgesics (indicated for Vomiting)
- Rectal Antiemetics
- Promethazine (Phenergan) 12.5 to 25 mg PR q4-6 hours
- Prochlorperazine (Compazine) 25 mg PR q12 hours
- Rectal Analgesics
- Indomethacin 50 mg, 1-2 PR at Headache onset
- Serotonin Agonist
- Ergotamine tartrate (Wigraine) suppository
- Use Ergotamine with caution due to adverse effects
- Management: Third-line Agents
- Precautions
- Expensive agents ($85 per tablet in 2020)
- Half the efficacy than Triptans
- Indications
- Indicated in Migraines refractory to at least two first-line Triptans
- Evaluate efficacy with standardized symptom score (see above)
- Gepant (CGRP receptor blocker)
- Ubrogepant (Ubrelvy)
- Rimegepant (Nurtec)
- Ditan (Selective Serotonin 5-Hydroxytryptamine receptor 1F agonst or 5-HT1F agonist)
- Schedule V due to euphoria and Hallucinations
- Lasmiditan (Reyvow)
- Management: Opioids
- Generally avoid Opioids in chronic Headache Management
- Indications
- Patients failing non-Opioid therapy
- Much less desirable for Headache Management
- Non-specific for Headache
- Addictive potential
- Stadol-NS (Butorphanol)
- Addictive (Class IV regulated substance)
- High abuse potential
- Dosing
- Stadol 1 spray in one nostril, repeat hourly prn
- Maximum 4 sprays per day or 6 sprays per week
- Limit to 2 days per week
- References
- (1995) Med Lett Drugs Ther 37(943) [PubMed]
- Moore (1997) Am Fam Physician 56(8):2039-48 [PubMed]
- Jackson (1998) CMEA Internal Medicine Lecture,San Diego
- Noble (1997) Am Fam Physician 56(9):2279-86 [PubMed]