Migraine abortives, also known as acute migraine medications, are treatments that stop a migraine attack once it has begun. Their purpose is to alleviate the pain and other symptoms associated with a migraine, such as nausea, vomiting, and sensitivity to light and sound. These medications are taken “as needed” at the onset of symptoms, rather than daily for prevention. They aim to interrupt the migraine cascade, providing relief and allowing individuals to resume normal activities.
Types of Migraine Abortive Medications
Over-the-counter (OTC) options are often the first line of treatment for mild to moderate migraine attacks. These include common pain relievers such as nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen, and acetaminophen. Combination products, such as those containing aspirin, acetaminophen, and caffeine, are also available and can be effective.
For moderate to severe migraines, prescription medications are recommended, with triptans being a common choice. Triptans are a class of drugs that act as serotonin receptor agonists, with examples including sumatriptan, zolmitriptan, and rizatriptan. These medications are available in various forms, such as oral tablets, nasal sprays, and injectable solutions, offering flexibility, especially with symptoms like nausea or vomiting.
Newer oral prescription options are CGRP receptor antagonists, known as gepants. These medications, such as rimegepant, ubrogepant, atogepant, and zavegepant, work by blocking the calcitonin gene-related peptide (CGRP) pathway. Gepants offer an alternative for individuals who may not respond to or tolerate triptans.
Another class of prescription abortives is serotonin 1F receptor agonists, or ditans. Lasmiditan is an example of a ditan for acute migraine treatment. Ditans are distinct from triptans because they do not cause vasoconstriction, making them a potential option for people with certain cardiovascular conditions.
Ergot alkaloids, such as ergotamine and dihydroergotamine, are an older class of migraine medications. Their role has become more limited due to a broader side effect profile and the development of newer, more targeted treatments. These medications can be administered in various forms, including pills, suppositories, nasal sprays, and injections.
Antiemetics are medications that help alleviate nausea and vomiting, common migraine symptoms. Examples include metoclopramide and prochlorperazine. These medications are often used in conjunction with other abortive treatments to improve symptom relief and aid in the absorption of oral medications.
How Migraine Abortives Work
Triptans target specific serotonin receptors, primarily 5-HT1B and 5-HT1D receptors, found on cranial blood vessels and nerve endings in the brain. By activating these receptors, triptans cause blood vessels in the brain to constrict and block pain signals transmitted by the trigeminal nerve. This reduces inflammation and swelling.
CGRP receptor antagonists, or gepants, block the activity of calcitonin gene-related peptide (CGRP). CGRP is a neuropeptide released during a migraine attack that contributes to pain signaling, inflammation, and blood vessel dilation in the brain. Gepants prevent CGRP from binding to its receptors, interrupting the pain pathway and reducing migraine symptoms without causing widespread blood vessel constriction.
Ditans, such as lasmiditan, selectively bind to the 5-HT1F serotonin receptor. These receptors are predominantly located in the brain and on the membranes covering the brain. By interacting with these receptors, ditans reduce the release of CGRP from the trigeminal nerve, diminishing pain processes without constricting blood vessels.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen work by reducing inflammation and blocking pain signals. NSAIDs inhibit cyclooxygenase (COX) enzymes, which are involved in prostaglandin production, contributing to inflammation and pain. Acetaminophen’s exact mechanism is not fully understood, but it also relieves mild pain.
Optimizing Abortive Treatment
Taking abortive medications at the earliest sign of migraine symptoms improves results. This means administering the medication during the prodrome phase (early warning signs), aura phase, or as soon as the headache begins. Early intervention can prevent the migraine from escalating in severity.
Following dosage instructions from a healthcare professional is important. Abortive treatments come in various forms, including oral tablets, dissolvable tablets, nasal sprays, and injections, each with specific guidelines. The choice of administration method can also be optimized based on individual symptoms, such as the presence of nausea or vomiting, which might make oral medications less effective.
If the initial dose of an abortive medication is not fully effective, it is important to know when a second dose is permitted or if a different abortive should be considered, as prescribed by a doctor. Most abortive drugs should not be used more than two to three days per week to avoid complications.
Potential Side Effects and Precautions
Migraine abortives can cause side effects. Common mild side effects include nausea, dizziness, drowsiness, muscle weakness, and tingling sensations. The specific side effects can vary depending on the medication class.
Triptans may cause chest tightness, flushing, or neck pain. They are not recommended for individuals with a history of cardiovascular disease, uncontrolled high blood pressure, stroke, or certain migraines like hemiplegic or basilar migraine, due to their vasoconstrictive properties.
A concern with frequent use of abortive medications is medication overuse headache (MOH), also known as rebound headache. This occurs when taking acute headache medications too often, more than 10 to 15 days per month, which can lead to more frequent and severe headaches. MOH can develop with various abortives, including triptans, ergots, and even some over-the-counter pain relievers.
Seek medical advice if side effects are severe or persistent, if the abortive medication is not providing enough relief, or if migraine frequency or severity increases. A healthcare provider can adjust the treatment plan, consider alternative medications, or explore preventive strategies to manage migraines effectively.