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Abortive treatment is an essential element of comprehensive and effective Migraine management.
When it comes to acute Migraine treatment, treating a Migraine in progress, most Migraine experts recommend Migraine abortive medications as the first-line treatment unless they are contraindicated (having reasons why they should not be used).
Migraine abortive medications work to stop the Migrainous process in the brain, thus stopping the symptoms as well. This is preferable to using pain medications, which can only mask the pain for a few hours, not actually stop the Migraine.
Migraine abortive medications have multiple actions:
- Since it was once thought that vasodilation in the brain (enlargement of blood vessels) was necessary for a Migraine, they constrict blood vessels to return dilated vessels to normal. It has now been shown that vasodilation may or may not occur during a Migraine and vasodilation is not necessary for a Migraine to occur.
- Abortive medications work to relieve inflammation because inflammation of nerves and some brain tissues does occur during a Migraine. This is one reason it’s important to use abortive medications as early in the Migraine as possible.
- Blocking the release of neurotransmitters such as serotonin is another way abortive medications work.
- Abortive medications also interrupt specific pain signals being sent to the brain.
The following are Migraine abortive medications:
- The triptan family:
- sumatriptan (Imitrex, Imigran, and Treximet, which is a combination of sumatriptan and naproxen sodium)
- rizatriptan (Maxalt, Maxalt-MLT)
- zolmitriptan (Zomig, Zomig-ZMT)
- naratriptan (Amerge, Naramig)
- eletriptan (Relpax)
- almotriptan (Axert)
- frovatriptan (Frova)
- Ergotamines:
- dihydroergotamine (D.H.E. 45), which can be used at home via subcutaneous injection
- dihydroergotamine (Migranal Nasal Spray)
- ergotamine tartrate and caffeine tablets (Cafergot, brand name is discontinued. Generics are still being manufactured.)
- ergotamine tartrate sublingual tablets (Ergomar)
- ergotamine tartrate and caffeine suppositories (Migergot)
- Isometheptene mucate compounds:
- Midrin, Epidrin, and others containing isometheptene mucate, acetaminophen and dichloralphenazone have been discontinued. (See Migraine Abortive Midrin and Equivalents Update 2/9/11.)
- Prodrin: contains isometheptene mucate, acetaminophen, and caffeine, and is still available.
- Those who used Midrin products can take a prescription to a compounding pharmacy and get an equivalent medication made.
- Inhaled oxygen:
Some studies have shown that high-flow inhaled oxygen is effective for some people in stopping cluster headaches. Although some people have reported that it helps with their Migraines, there is no study data to support the use of oxygen as a Migraine abortive.
Sumatriptan and naratriptan are now available in generic forms. All seven triptans are available in tablets for oral administration. Sumatriptan and zolmitriptan (Zomig) are available in nasal spray. Sumatriptan is now available in a number of injectable forms: Imitrex StatDose, Sumavel DosePro needle-free injections, Alsuma injections similar to an Epi-pen, and single dose vials that can be drawn into an insulin syringe for subcutaneous injection.
A problem with currently available abortive medications is that they carry warnings and contraindications for some groups of Migraineurs. It’s recommended that triptans and ergotamines not be used by Migraineurs who:
- have a history of or significant risk factors for heart disease, coronary vasospasm, or any significant cardiovascular issue.
- have a history of significant risk factors for stroke, TIA, or other cerebrovascular issues.
- have peripheral vascular disease including ischemic bowel disease.
- have uncontrolled hypertension.
- have basilar-type or hemiplegic Migraines.
The isometheptene mucate medications, such as Midrin, have never carried warnings or contraindications such as those listed above for triptans and ergotamines. Many doctors have prescribed those medications for people for whom they were uncomfortable prescribing triptans and ergotamines because of the warnings and contraindications. However, some Migraine specialists are of the opinion that since isometheptene mucate has vasoconstrictive properties, medications made with it are no safer than triptans or ergotamines.
As with other acute medications, care must be taken not to overuse Migraine abortive medications. Using them more than two or three days a week can lead to medication overuse headache. (See Help! How Can I Not Overuse Migraine Medications?)
The future of abortive medications:
The next wave of abortive medications under investigation are CGRP (calcitonin gene-related pepitide) inhibitor medications. The first of these, Telcagepant, is currently in clinical trials.
Here’s an explanation of CGRP and CGRP inhibitors from a study by Ho et al:
“Calcitonin gene-related peptide (CGRP) is a neuropeptide thought to have a key role in the pathophysiology of migraine. CGRP concentrations in the cranial circulation may be increased during a migraine attack and CGRP given intravenously triggers a migraine-like headache in people who have migraines. CGRP receptors are found throughout the trigeminal pathways involved in migraine headache pain and have been localised to primary sensory neurons in the trigeminal ganglion, central second-order pain-relay neurons in the trigeminal nucleus caudalis, and smooth muscle cells of the meningeal vasculature. Antagonism of these receptors has thus become an important target for new migraine treatments. Since antagonists of CGRP receptor do not seem to have direct vasoconstrictor properties, they might be free of the cardiovascular concerns associated with triptans.”
At this time, it’s uncertain, but it’s possible that the action of these CGRP inhibitor medications will not be vasoconstrictive, so they may be deemed safe for people with cardio- and cerebrovascular issues that preclude their use of current abortive medications.
As mentioned above, not all Migraineurs can use abortive medications because of contraindications. There are also times when abortive medications fail. They may work for us most of the time, but not all the time, and – infrequently – there are people who have found an abortive medication that works for them.
In either case, we then move on to medications that are usually reserved for use as rescue medications, medications to be used when abortives fail or can’t be used. These are typically NSAIDs or analgesics, and they’re often used in combination with medications to treat nausea. I’ll go into greater detail about these medications in Migraine Management Essential 6: Rescue Treatment.
Live well,
© Teri Robert, 2011
Migraine Management Essentials Series
____________
Resources:
- Interview: Teri Robert with John Claude Krusz, PhD, MD. February 26, 2011.
- Ho, Dr. Tony W., MD; Ferrari, Prof. Michael D, MD; Dodick, Prof. David W., MD; Galet, Vince, PhD; Kost, James, PhD; Fan, Xiaoyn, PhD; Leibensperger, Heather, BS; Froman, Samar, BS, Assaid, Christopher, PhD; Oines, Christopher, PhD; Koppen, Hille, MD; Winner, Paul K., DO. “Efficacy and tolerability of MK-0974 (telcagepant), a new oral antagonist of calcitonin gene-related peptide receptor, compared with zolmitriptan for acute migraine: a randomised, placebo-controlled, parallel-treatment trial.” The Lancet, Early Online Publication. November 25, 2008.
- Robert, Teri. “Living Well with Migraine Disease and Headaches.” New York. HarperCollins. 2005.
- Cohen, Anna S., PhD, MRCP; Burns, Brian, MD, MRCP; Goadsby, Peter J. MD, PhD, DSc, FRACP, FRCP. “Hight-Flow Oxygen for Treatment of Cluster Headache.” JAMA, December 9, 2009—Vol 302, No. 22.
- Interview: Teri Robert with Tony Ho., M.D., senior director of Clinical Neurosciences, Merck Research Laboratories. June 7, 2007.
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Discuss
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Stacie Powers Hatfield (Thu, 10 Mar 2011 14:32:44 +0000): As a migraine cluster sufferer the past 8+ years (including today), currently medicating, I just found your cite this morning. I have run the gambit on preventative & abortive meds to no avail and have an appt with a migraine specialist at St. Louis University in May, hoping for something to help. I've been told "there's nothing I can do for you....you're just going to have these migraines the rest of your life" by a so-called neuro out of mobap on my first visit with him for a 2nd opinion. Needless to say, never went back to him. Looking forward to perusing your cite in more detail when I can see straight again haha. Thank you for posting!
Michelle Singleton (Wed, 16 Mar 2011 21:25:11 +0000): I just as of recetly found this website and I am glad that I have... I am 29 yrs old and have suffered from migraines since 14 and have been on so many different things that worked and failed... However there is still no actual release what works now may not be working in three months and it's a continued search. However I am realizing that I'm not alone in realizing that there is no quick treatment or fix... People that have never experienced it or have family that has they think it's as simple as popping excedrin migraine or tylenol... So with all that said I'm just glad that I'm not alone.
Charles Andrew Lininger (Wed, 22 Jun 2011 12:48:01 +0000): I use acupuncture as an abortive treatment in acute migraine. The correct protocol has rapid action. It is immediately applicable for any trained acupuncturist, recently an associate used this protocol for the first time for a patient with acute migraine with a good outcome.
Brynda Jolly Bechtold (Thu, 23 Jun 2011 03:10:53 +0000): I had acupunture today at our local school "Daoist Traditions." Been about 10 yrs since I had any. Students learning on me, but it's powerful. They are so thorough.
"My migraines, when at their worst would have me throwing up and unable to really focus or concentrate. I used to still go into work sometimes having to pull over and throw up on the side of the road." 
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I will try that…don’t know if it will work. My insurance is held by my spouse, and they aren’t really caring about your problems with migraines.
Thanks for the great articles, I am sharing them on facebook.
Susieg720
Oops! Sorry, susieg. I also meant to thank you for commenting and tell you I’m glad you like the article. I got carried away talking about insurance issues. :-O
Teri
I hear you susieg! My insurance company limits my triptans too. Yours limits to nine for THREE months? That’s usually the limit for one month. Have you checked to see if they’ll cover more if you get a letter from your doctor and get it approved before sending in your prescription? Some will do that.
Is your insurance through your or your spouse’s employer? If so, it could help to talk with someone in the human resources department. Such limits are set by the level of coverage that’s contracted too. That’s something else that we often don’t know.
Something else to explore – Would your insurance company pay for more doses of a different triptan? In other words, are you using their “preferred” triptan? Insurance companies often work with pharmaceutical companies to get better prices, and their “preferred” medications are those for which they get lower prices. If sumatriptan (Imitrex) works for you, you might also check to see how many doses of generic sumatriptan they’d cover.
Let’s face it. Insurance companies don’t exist to help us with our medical care. They exist to make a profit. They have stock holders who expect quarterly dividends. It’s a great premise, but the cost of medical care and prescription drugs has risen so much that insurance companies have to limit high-cost medications to keep making their profits.
Teri
Good article…. My only problem is my insurance company will not pay for more than 9 pills and this is to last me for 3 months.
I am so very tired of dealing with insurance people….they don’t care and they are not paying for more meds…so your stuck between a rock and a hard place…lol.
You just deal with the migraines as best you can, insurance people don’t really care.
Thanks,
Susieg720