Abortive treatment for Migraine Headache

1.

Elsevier ClinicalKey Clinical Overview

Treatment Therapy involves treatment of acute headache and/or prevention of subsequent migraine Acute (abortive) therapy Preventive therapy Other therapies Treatment of status migrainosus (emergency department or inpatient setting) focuses on hydration and nonopioid IV medications; no specific medication protocol has proved to be most efficacious Analgesics Over-the-counter analgesics are first line therapy for mild to moderate acute migraine NSAIDs Acetaminophen-aspirin-caffeine combination Prescription NSAIDs Celecoxib oral solution is indicated for the acute treatment of migraine with or without aura in adults Triptans For moderate to severe acute migraine and for mild migraine that does not respond to analgesics Use NSAID plus triptan for prolonged or recurring migraine Ergotamine preparations For moderate to severe acute migraine and for mild migraine that does not respond to analgesics Serotonin agonist Lasmiditan is available in tablet form and is indicated for the acute treatment of migraine with or without aura in adults Small-molecule CGRP (calcitonin gene–related peptide) receptor antagonists Rimegepant is available as an orally disintegrating tablet and is indicated for acute treatment of migraine with or without aura Ubrogepant is available in tablet form and is indicated for the acute treatment of migraine with or without aura in adults Zavegepant is available as a nasal spray and is indicated for the acute treatment of migraine with or without aura in adults Antiemetics For nausea and vomiting during acute migraine Remote electrical neuromodulation Available as a wireless, wearable, noninvasive, battery-operated, remote electrical neuromodulation device controlled by a smartphone application FDA-authorized device is approved for treatment of acute migraine with or without aura in people aged 12 years and older

Treatment Acute (abortive) therapy Analgesics NSAIDs For mild to moderate migraine NSAIDs are first line therapy for patients with moderate to severe migraine for whom triptans are contraindicated, who are intolerant of triptans, or who respond poorly to triptans Should be avoided after 20 weeks of gestation in pregnant patients Celecoxib oral solution Celecoxib Oral solution; Adults: 120 mg PO once daily for the fewest number of days per month as needed. Max: 120 mg/day. Ibuprofen Ibuprofen Oral tablet; Adults: 200 to 400 mg PO as a single dose. Naproxen Naproxen Oral tablet; Adults: 500 mg PO as a single dose. Ketorolac For treatment of status migrainosus Ketorolac Tromethamine Solution for injection; Adults 18 to 64 years weighing 50 kg or more: 30 mg IV as a single dose. Acetaminophen-aspirin-caffeine combination Acetaminophen, Aspirin, Caffeine Oral tablet; Adults: 500 mg acetaminophen/500 mg aspirin/130 mg caffeine PO as a single dose. Max: 500 mg/day acetaminophen/500 mg/day aspirin/130 mg/day caffeine. Triptans For moderate to severe acute migraine and for mild migraine that does not respond to analgesics Use NSAIDs plus triptans for prolonged or recurring migraine Sumatriptan Oral Sumatriptan Succinate Oral tablet; Adults: 25, 50, or 100 mg PO as a single dose. May repeat dose once after at least 2 hours after the first dose if headache has not resolved or returns after transient improvement. Max: 200 mg/day.

2.

Elsevier ClinicalKey Drug Monograph

Content last updated: February 2, 2024.

Description Migergot are used in combination as an abortive treatment for migraine and cluster headaches. This medication is still considered a primary treatment option by many clinicians because of its efficacy in controlling up to 70% of migraine attacks in adults and its relative cost advantage compared to other anti-migraine medications. Prolonged use or excessive dosage of this drug combination can lead to ergotism, dependence, and/or rebound headaches. Migergot should be prescribed in strict accordance with the manufacturer's guidelines. Maximum daily and weekly dosage limits should not be exceeded. A suppository formulation of the drug is available for those who cannot tolerate oral administration due to nausea/vomiting during migraine attacks. Ergotamine was first used medically to treat migraines in the 1920s, and was approved by the FDA in 1960.

3.

Digre, Kathleen B. (2024). In Goldman-Cecil Medicine (pp. 2376). DOI: 10.1016/B978-0-323-93038-3.00367-1

Ergotamine given early in the migraine attack can be effective if the associated nausea and peripheral vasoconstriction are tolerable. Lasmitidan (50 to 200mg) is a serotonin receptor agonist that does not have the vasoconstrictive side effects of triptans and that is safe and effective for patients who have contraindications to triptans; however, it is sedating, so driving is contraindicated for at least 90minutes and perhaps up to 8hours after its administration. Small-molecule, calcitonin gene–related peptide receptor antagonists are also helpful for treating migraine attacks. Both rimegepant (75mg orally) or ubrogepant (50 to 100mg) can provide about a 10% absolute increase in pain freedom within 2 hours compared with placebo,,have few side effects, and are useful when triptans are not successful or are contraindicated.Ubrogepant is also effective when taken during a migraine prodrome.Another rapid-acting option is zavegepant (10 mg) nasal spray. Forvery severeattacks, dihydroergotamine (1mg subcutaneously or 0.5 to 1mg intravenously [IV]) is usually effective but generally requires an antiemetic (e.g., promethazine, 25mg) before intravenous use. Ketorolac (60mg intramuscularly [IM] or 30mg IV), prochlorperazine (10 to 25mg IM or 10mg IVdelivered over a 5-minute period), metoclopramide (10mg IV), or celecoxcib solution (120mg orally)is useful for patients who are nonresponsive or have contraindications to vasoactive abortive agents. Opioids should not be used except as a last resort.

Treatment of migraineis divided into treatment of the acute headache and prevention of subsequent migraine attacks (seeFig. 367-1andhttps://americanheadachesociety.org/flowchart/). Acute treatment is most effectively accomplished with migraine-specific care: a nonspecific analgesic agent or combination analgesic therapy for milder migraine and, most frequently, aggressive migraine-specific therapy for migraine. Stratification of care, including tailoring the treatment according to the type of headache, results in fewer days of disability and use of medications.Which migraine-specific drug will work for any individual patient depends on the patient. It is important to avoid overuse of analgesic and other medications (especially opiates) because overuse can cause chronic daily headache in susceptible individuals. Prompt treatment improves the outcome of headache when compared with late treatment. Mildattacks can generally be treated successfully with over-the-counter analgesics such as acetaminophen (suggested dose, 650 to 1000mg) or NSAIDs (aspirin, 250mg to 1000mg; ibuprofen, 400 to 600mg; naproxen, 500 to 825mg; diclofenac, 50mg; or ketoprofen, 75mg). Formoderate to severemigraine headaches, patients benefit from migraine-specific triptans (seeTable 367-5), ergotamines (dihydroergotamine 1 to 2 mg intranasally or subcutaneously; ergotamine tartrate, 2mg sublingually or 1 to 2mg orally), the combination of naproxen and a triptan, or a formulary combination of isometheptene (65mg), dichlorphenazone (100mg), and acetaminophen (325mg).Contraindications to use of triptans include uncontrolled hypertension, clinical evidence of ischemic heart disease, and Prinzmetal angina. Ergotamine given early in the migraine attack can be effective if the associated nausea and peripheral vasoconstriction are tolerable.

4.

Food and Drug Administration (DailyMed).

Publish date: November 2, 2022.

Indications And Usage INDICATIONS AND USAGE MIGERGOT (ergotamine tartrate and caffeine) Indicated as therapy to abort or prevent vascular headache, e.g., migraine, migraine variants or so-called “histaminic cephalalgia”.

5.

Food and Drug Administration (DailyMed).

Publish date: December 2, 2021.

Indications And Usage INDICATIONS AND USAGE Ergotamine tartrate and caffeine tablets are indicated as therapy to abort or prevent vascular headache; e.g., migraine, migraine variants or so-called “histaminic cephalalgia.”

6.

Elsevier ClinicalKey Drug Monograph

Content last updated: March 5, 2024.

Indications And Dosage **For the acute treatment of migraine attacks in patients with a history of migraine with or without aura** NOTE: Use axert only when a clear diagnosis of migraine is established. If a patient does not respond to axert for the first migraine attack, re-evaluate the diagnosis of migraine prior to subsequent use. Axert is not indicated for migraine prophylaxis or for the treatment of hemiplegic or basilar migraines or cluster headaches. **for the acute treatment of migraine attacks in adults with a history of migraine with or without aura** Oral dosage Adults: 6.25 or 12.5 mg PO once, with 12.5 mg tending to be a more effective dose. May repeat dose after 2 hours if the headache returns. Max: 25 mg/day. Controlled trials have not adequately established the effectiveness of a second dose if the initial dose is ineffective. Single doses more than 12.5 mg do not improve efficacy. The safety of treating more than 4 headaches in a 30-day period has not been established. Guidelines classify axert as having established efficacy for the treatment of acute migraine. **for the acute treatment of migraine headache pain in pediatric patients with a history of migraine attacks with or without aura usually lasting 4 hours or more (when untreated)** Oral dosage Children and Adolescents 12 to 17 years: 6.25 or 12.5 mg PO once. May repeat dose after 2 hours if the headache returns. Max: 25 mg/day. The efficacy on migraine-associated symptoms (i.e., nausea, photophobia, and phonophobia) and the safety of treating more than 4 headaches in a 30-day period have not been established. Guidelines recommend axert for acute treatment of migraine in adolescents; however, those receiving axert are possibly no more likely that those receiving placebo to be headache-free at 2 hours. **for the acute treatment of migraine attacks in adults with a history of migraine with or without aura** Oral dosage Adults: 6.25 or 12.5 mg PO once, with 12.5 mg tending to be a more effective dose. May repeat dose after 2 hours if the headache returns.