Abortive Headache Medications
Pearls
-
Take the maximum allowable dosage of prescribed medication at the very earliest sign of headache.
-
Best Practice: Combine rescue medication with different mechanisms of action (i.e. NSAID + triptan + antiemetic). Rescue medications are more effective if taken together than taken alone.
-
For patients with significant nausea and vomiting during migraine attacks, prefer non-oral rescue options (e.g., sumatriptan nasal spray or injection) and cotherapy with an antiemetic (e.g., reglan, compazine, zofran).
-
Limit use of acute treatments (over-the-counter medications, triptans, etc.) to no more than 2 days per week or 10 days per month to prevent medication overuse headache (rebound headache).
-
Avoid prescribing opioid or butalbital combination medications.
-
For patients who don't tolerate medications, consider Cefaly (see details below).
Over-The-Counter Medications
Drug | Dose |
|---|---|
Naproxen (Aleve) | Take 500-750 mg once at migraine onset. Take with food. Do not exceed 1,000 mg daily. |
Ibuprofen (Motrin, Advil) | Take 800 mg at migraine onset. May take an additional 800 mg every 8 hours as needed for migraine. Take with food. Do not exceed 3,200 mg daily. |
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Contraindications | Warnings | Common ADEs |
|---|---|---|
Active GI bleed or ulcer, Uncontrolled heart failure, CrCl < 30 mL/min.
| Hyperkalemia, increases risk for cardiovascular events, bleeding and acute kidney injury.
| Dizziness, heartburn, nausea. |
Drug | Dose | Contraindications | Common ADEs |
|---|---|---|---|
Acetaminophen (Tylenol) | Take 1000 mg once at migraine onset. May take an additional 1000 mg every 6 hours as needed for migraine. Do not exceed 4000 mg daily. Do not exceed 1300 mg per single dose. | Hepatic impairment | Nausea, vomiting |
Analgesic Medication
Triptans (Serotonin Receptor Agonists)
Contraindications | Warnings | Common ADEs |
|---|---|---|
CVD (vascular disease, stroke/TIA, prior MI, CAD, ischemic heart disease, ischemic bowel disease, PVD). | Cardiac arrhythmias, cardiac events, ocular events, serotonin syndrome, CNS effects (dizziness, asthenia, drowsiness, tremor, vertigo, dystonia). | Chest tightness, throat discomfort, nausea, dizziness, paresthesia, flushing, tingling sensation, feeling hot. |
Drug | Dosage |
|---|---|
Sumatriptan Nasal Spray | 10 mg once at the first onset of migraine (10 mg in single nostril). May repeat in 2 hours. Max total daily dose is 30 mg. |
Sumatriptan Tablet | 25-100 mg once at the first onset of a migraine attack. May repeat in 2 hours. Max total daily dose is 200 mg. |
Sumatriptan Injection | 4 mg once at the first onset of a migraine attack. May repeat in 1 hour if attack does not subside. May increase injection to 6 mg. Max total daily dose is 12 mg. |
Rizatriptan | Tablet or Oral Disintegrating Tablet: 5-10 mg once at the first onset of migraine. May repeat in 2 hours. Max daily dose is 30 mg. |
Naratriptan (preferred for px with long lasting migraines episodes or episodes that recur despite multiple dosing of rescue medications) | Tablet: 2.5 mg once at the first onset of migraine. May repeat in 4 hours.
Mild-mod CKD: Initial 1 mg, Max total daily dose is 2.5 mg. CrCl<15: AVOID/Contraindicated.
|
Gepants (CGRP Receptor Inhibitors)
Contraindications | Common ADEs |
|---|---|
Strong CYP3A4 inhibitors. | Nausea, GI side effects. |
Drug | Dosage |
|---|---|
Ubrogepant (Ubrelvy) | Take 50-100 mg at migraine onset. Can repeat in 2 hours. Do not take more than 200 mg in 24 hours. CrCl 15-29: Max total daily dose 100 mg.
CrCl < 15: AVOID.
|
Rimegepant (Nurtec) | Without drug interactions: 75 mg once every 24 hours as needed at the start of migraine symptoms. With weak-moderate CYP3A4 inhibitors: 75 mg once every 48 hours as needed at the start of migraine symptoms.
CrCl < 15: AVOID.
|
Ditans (5HT1F Selective Serotonin Receptor Agonists)
Drug | Dose | Warnings | Common ADEs |
|---|---|---|---|
Lasmiditan (Reyvow) | Initial: 50 to 100 mg as a single dose. May increase to 100 or 200 mg as a single dose with subsequent attacks if needed. Maximum: One dose per 24 hours. | Schedule 5 controlled substance. Do NOT drive 8 hours after administration. | Dizziness |
Ergot Derivative (serotonin, noradrenaline & dopamine agonist)
Drug | Dose |
|---|---|
Dihydroergotamine (DHE) Nasal Spray | 0.5 mg (one spray) into each nostril at the first onset of migraine. May repeat in 15 minutes. Max daily dose=4 mg (4 doses). |
Dihydroergotamine (DHE) Injection | 1 mg once at the first onset of migraine. May repeat hourly if migraine persists. Not to exceed 3 mg per day or 6 mg per week. |
Contraindications | Warnings | Common ADEs |
|---|---|---|
Peripheral vascular disease, hepatic or renal impairment, CAD, history of MI, hypertension, strong CYP3A4 inhibitors, pregnancy, breastfeeding or women of childbearing age.
| Vasoconstriction, avoid use in older adults, high risk for medication overuse headache (use of rescue more than 10 days per month).
| Nausea, vomiting, hot flash, diarrhea. Nasal spray: local irritation to nose and throat, rhinitis. |
Combination Medications
Dose | Warnings |
|---|---|
2 tablets as a single dose. Maximum: 2 tablets per 24 hours. | Aspirin may increase risk of GI ulcer and bleeding concerns.
Acetaminophen may increase risk of hepatotoxicity. |
Excedrin is available to patients over-the-counter, while Fioricet and Cafergot require a prescription.
Dose | Warnings | Common ADEs |
|---|---|---|
1 to 2 tablets every 4 hours as needed; not to exceed 6 tablets daily. | Medication overuse headache (MOH): strongly associated with transformation from episodic to chronic headache, dependance and abuse. Reserve use for patients without alternative options. Limit use to ≤3 days per month to avoid MOH. | Dizziness, drowsiness, sedation, abdominal pain, nausea, vomiting, dyspnea. |
Dose | Contraindications | Warnings | Common ADEs |
|---|---|---|---|
2 tablets at onset. If symptoms persist, administer 1 tablet every 30 minutes PRN, not to exceed 6 tablets per attack/day and do not exceed 10 tablets per week. | Peripheral vascular disease, hepatic or renal impairment, CAD, uncontrolled HTN, strong CYP3A4 inhibitors, pregnancy or women of childbearing age.
| Vasoconstriction; avoid use in older adults.
| Bradycardia, ECG changes, hypertension, gangrene of skin, myalgia. |
Excedrin
Acetaminophen 250 mg, Aspirin 250 mg, Caffeine 65 mg
Fioricet Tablet
Butalbital 50 mg, Acetaminophen 325 mg, Caffeine 40 mg
Cafergot
Ergotamine 1 mg, Caffeine 100 mg
Antiemetics & Other Mechanisms of Action
Metoclopramide
Antiemetic; Dopamine Antagonist; GI Agent, Prokinetic; Serotonin 5-HT4 Receptor Agonist
Dose | Contraindications | Warnings | Common ADEs |
|---|---|---|---|
Initial: 10 mg once daily as needed. CrCl 10-60: Administer ~50% of usual dose. CrCl < 10: Administer less than ⅓ of usual dose or do not use.
| Seizure disorders, mechanical GI obstruction/perforation/hemorrhage, history of tardive dyskinesia or concomitant use of other agents likely to increase EPS reactions.
| CNS depression, extrapyramidal symptoms (EPS), hyperprolactinemia. | Dizziness, drowsiness, fatigue, restlessness. |
Prochlorperazine
Antiemetic; First Generation (Typical) Antipsychotic
Promethazine
Antiemetic; Histamine H1 Antagonist
Dose | Contraindications | Warnings | Common ADEs |
|---|---|---|---|
Initial: 5-10 mg every 6-8h as needed. Max: 40 mg/d. | Large amounts of other CNS depressants. | Altered cardiac conduction, anticholinergic effects, CNS depression, extrapyramidal symptoms, orthostatic hypotension. | Hypotension, ECG abnormality, peripheral edema. |
Dose | Contraindications | Warnings | Common ADEs |
|---|---|---|---|
Initial: 12.5-25 mg every 4-6h as needed.
Max: 50 mg/d. | Asthma | Respiratory disease (COPD, sleep apnea), seizures, anticholinergic effects, CNS depression, extrapyramidal symptoms, orthostatic hypotension. | Hypotension, bradycardia, CNS depression, extrapyramidal symptoms. |
Non-Pharmacologic Options
Migraine Treatment Devices
-
Cefaly and HeadaTerm 2 are devices FDA approved for migraine treatment.
-
Both devices are non-invasive and non-pharmacologic.
-
These devices can be used in conjunction with headache medications or alone.
-
These devices do not require a prescription and patients can purchase using their Health Savings Account (HSA) or Flexible Spending Account (FSA).
-
-
The devices use an adhesive to temporarily stick to your forehead and deliver electric impulses to the forehead as an approach to reducing headaches.
-
Patients can use these devices for both acute and preventative treatment.
-
-
Trying Cefaly
-
Cefaly typically costs about $400*, which isn't accessible for everyone.
-
CEFALY.com does offer a full refund to patients within 90 days of purchase.* It's safest to confirm this return policy with the vendor before purchasing.
-
-
-
Trying HeadaTerm 2
-
HeadaTerm 2 typically costs about $100* and has a 30 day money back guarantee* if patients purchase from Emeterm.com
-
Abortive Medications List PDF
Consider downloading and saving the following PDF for quick access to this list of first-line abortive medications.
Last updated 10/14/24*