Migraine Management Essential 5: Abortive Treatment

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 October 2011.)
  • 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.

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