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Migraine abortives

Marcello Cherchi M.D. Ph.D., Chicago IL and Timothy C. Hain, MD, Chicago IL

Page last modified: October 13, 2016 See also -- many pages on migraine on this site

Migraine abortives are medications taken after a headache starts, in an attempt to prevent it from progressing. They are different from prophylactic drugs (taken daily).

The following incomplete list includes medications, discussed in the medical literature, and each of which has been asked about by patients in our practice in Chicago at some point.  The list contains some comments regarding our prescribing practices, but we do not endorse any particular drugs. When applicable, we have added in the recommendations of review articles concerning abortives, such as that by Orr et al (2015), although in many instances these recommendations violate clinical experience and common sense.

This list implies that "migraine" is a monolithic disease where the best treatment can be elucidated by evidence, such as a double-blind placebo controlled trial. Actually, genetic studies suggest that there are many genetic variants associated with the collection of symptoms called "migraine", and a "splitter" could reasonably argue that these are all different diseases. Logically then, medications might work better in genetic subvariants, and the clinical evidence should be looked at as dubious, as it presumes that "migraine" is a disease. In our opinion, clinical experience can help the astute clinician pick medications that are more likely to be effective for variants of "migraine", but often the treatment process involves trial/error.

Triptans

Triptans are the prototype migraine abortive drug. At this writing, this category includes sumatriptan, naratriptan, zolmitriptan, rizatriptan, almotriptan, frovatriptan and eletriptan. These drugs are all group-1 agents. These drugs are 5HT-1B and 1D (serotonin) receptor agonists. Some also affect 5HT-1F. Serotonin does a lot of things in the body and there are many receptors, presently ranging from 5HT1-7. The table below contains an overview of the timing of these drugs. Tmax is the time when the effect peaks. T 1/2 tells you (approximately) how long the effect lasts. As a general rule, it takes 5 half-lives for a drug to be completely eliminated -- thus this varies from about 10 hours to 5 days. The Canadian Headache Society states that they recommend sumatriptan (one of these) based on a "moderate level of evidence" (Orr, 2015). This is reasonable and we think the recommendation applies to almost all triptans. Tryptans have good evidence (level A) for effectiveness according to the American Headache Society (Marmura et al, 2015).

Compound Dose Tmax T 1/2
Rizatriptan (Maxalt) 10 1 2-2.5
Eletriptan (Relpax) 40 1-1.25 4-7
Sumatriptan (Imitrex) 100 2.5 2-2.5
Zolmitriptan (zomig) 2.5 2.5 3
Almotriptan (Axert) 12.5 2.5 3.6
Naratriptan (Amerge) 2.5 2-3 5-6
Frovatriptan (Frova) 2.5 2-4 25
(modified from Matthew and Loder, 2005)

 

Chemical name:                 Almotriptan

Chemical name:                 Eletriptan

Chemical name:                 Frovatriptan

Chemical name:                 Naratriptan

Chemical name:                 Rizatriptan

Chemical name:                 Sumatriptan

Chemical name:                 Zolmitriptan

Ergot derivatives

Chemical name:                 Dihydroergotamine (DHE)

Chemical name:                 Dihydroergotamine (DHE) nasal

Chemical name:                 Ergotamine / caffeine

Dopamine antagonists

Chemical name:                 Chlorpromazine

Chemical name:                 Droperidol

Chemical name:                 Haloperidol

Chemical name:                 Metoclopramide (+ diphenhydramine)

Chemical name:                 Prochlorperazine

Other Medications for Migraine (non-triptan, non ergot, non anti-emetic)

Chemical name:                 Magnesium sulfate

Chemical name:                 Meperidine + promethazine

Chemical name:                 Methylprednisolone

Chemical name:                 IV valproate

Caffeine, aspirin, acetaminophen.  Efficacy of each drug individually was shown in randomized, double-blind, placebo-controlled trials (Smith 1998).

Nonsteroidals

Nonsteroidal antiinflammatory agents include aspirin, naproxen, ibuprofen, and an immense number of other pain relievers. They share several features -- they are generally not addictive, they generally irritate the stomach, and they occasionally are associated with increased blood pressure and worsening of kidney function. Many of these are "OTC" or over the counter agents. Recently there have been a few that seem particularly suitable for migraine treatment.

We generally first suggest patients try the simple OTC NSAID's such as aspirin (500 mg). This includes some combination products such as "Excedrin migraine". If this is not enough, then we often suggest indomethacin (indocin), with care not to take it very often because of stomach irritation.

Cambia (diclofenac) -- a powder that is dissolved in your liquid of choice. Again, very powerful. The Candian headache society disagrees saying that based on low-quality evidence, we recommend weakly against the use of diclofenac (Orr, 2015). This adverse recommendation is routinely contradicted by our patients who say that Cambia works very well. We think it is especially helpful in hemiplegic migraine. According to the American Headache society, the evidence for efficacy is level A (Marmura et al, 2015).

Naproxen was studied in randomized, double-blind, placebo-controlled trials (Andersson et al. 1989).  The trial showed that naproxen diminished headache severity at 2 hrs., though it did not improve the attack overall.  A double-blind, parallel group study found naproxen and ergotamine to have similar efficacy (Treves et al. 1992). The typical dose is 500 or 550. According to the American Headache society, the evidence for efficacy is level A (Marmura et al, 2015).

Ketoprofen 100 mg is, according to the American Headache society, evidence for efficacy at level B (Marmura et al, 2015).

The Canadian headache society stated that " We strongly recommend the use of ... ketorolac, based on a low level of evidence". (Orr, 2015) Our take on this is that all of the nonsteroidals do the same thing, and they should all work.

The American Headache Society had no comments about the Cox-2 NSAID's (such as Celebrex) for migraine (Marmura, 2015). We have not encountered their use at all in our patients in Chicago.

Newer nonsteroidal agents that can be used as abortives in migraine include

SPRIX (nasal spray form of ketorolac) -- a very powerful drug. According to the American Headache society, the evidence for efficacy is level C negative (Marmura et al, 2015). This would suggest that it is not effective. On the other hand, ketorolac IV or IM (30-60 mg) is, According to the American Headache society, the evidence for efficacy is level B (Marmura et al, 2015). So as of 2015, it would seem that Sprix is not effective, but IV or IM ketorolac is effective.

The combination of indomethacin, prochlorperazine and caffeine suppositories was shown to be comparable to sumatriptan in a randomized, double-blind, parallel group trial (Sandrini et al. 2007), and was shown to be more efficacious than sumatriptan in a randomized, double-blind, crossover trial (Di Monda et al. 2003). This formulation is not generally available.

Opiates (i.e. codeine, oxycodone, etc).

Most neurologists are very reluctant to prescribe opiates for Migraine because there is a strong tendency to develop addiction. These include butorphanol IM, Codeine 30, Meperidine (demerol) IM 75, Methadone IM 10, Tramadol IV 100. According to the American Headache society, the evidence for efficacy is level C (Marmura et al, 2015). Strangely, missing from this list provided by the American Headache Society, is oxocodone, which we feel is used very commonly. It is certainly addictive as well. There are many other opiates -- addiction is the problem common to all of them.

References

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