Acute Treatment Options for Migraine
Migraine is a neurovascular disorder driven by cortical spreading depression, trigeminovascular activation with CGRP release, and central sensitization. Acute treatment aims to abort the attack, and the choice of agent is matched to attack severity and to patient-specific contraindications. The core classes are simple analgesics, triptans, anti-emetics, gepants (CGRP receptor antagonists), and ditans (5-HT1F agonists).
Simple Analgesics
Aspirin, NSAIDs, and acetaminophen are the first-line agents for mild-to-moderate migraine. They are widely available and effective for lower-severity attacks. Their major limitation is that frequent use risks converting episodic headache into medication overuse headache (chronic daily headache), so patients should be counseled to avoid frequent dosing.
Triptans
Triptans such as sumatriptan and rizatriptan are first-line for moderate-to-severe migraine. Mechanistically, they constrict cranial vessels and inhibit CGRP release, directly targeting the trigeminovascular pathway. Because of their vasoconstrictive action, triptans are contraindicated in coronary artery disease. Sumatriptan (subcutaneous) is also a first-line acute abortive for cluster headache.
Anti-emetics
Metoclopramide and prochlorperazine are useful adjuncts in acute migraine, addressing the nausea and vomiting that accompany attacks. Beyond controlling nausea, these dopamine-blocking agents may have an intrinsic anti-migraine effect. Note that both are dopamine receptor blockers and therefore carry a risk of medication-induced parkinsonism and other extrapyramidal effects with use.
Gepants
Ubrogepant and rimegepant are gepants — small-molecule CGRP receptor antagonists. Because CGRP is a key mediator of migraine (released during trigeminovascular activation), blocking its receptor aborts the attack. Gepants serve as an alternative to triptans, which is particularly valuable in patients in whom triptan vasoconstriction is undesirable.
Ditans
Lasmiditan is a ditan, a selective 5-HT1F agonist. Unlike triptans, it produces no vasoconstriction, making it an option where vascular risk is a concern. Its trade-off is prominent CNS effects (e.g., sedation/dizziness), which limit tolerability and activities such as driving after dosing.
High-yield
- Migraine pathophysiology: cortical spreading depression → aura; trigeminovascular CGRP release → neurogenic meningeal inflammation; central sensitization.
- Simple analgesics (aspirin, NSAIDs, acetaminophen) = first-line for mild-moderate migraine.
- Triptans (sumatriptan, rizatriptan) = first-line for moderate-severe migraine; contraindicated in CAD.
- Triptans work by cranial vasoconstriction AND inhibition of CGRP release.
- Gepants (ubrogepant, rimegepant) = CGRP receptor antagonists; a non-vasoconstrictive alternative to triptans.
- Ditans (lasmiditan) = 5-HT1F agonists with no vasoconstriction but notable CNS effects.
- Frequent acute analgesic use → medication overuse headache (chronic daily headache); treat by withdrawing the offending agent.
- Anti-emetics (metoclopramide, prochlorperazine) are helpful adjuncts and may have intrinsic anti-migraine effect.
Pitfalls
- Giving triptans to a patient with coronary artery disease — the vasoconstrictive mechanism makes this a contraindication; consider a gepant or ditan instead.
- Assuming a ditan behaves like a triptan — lasmiditan does NOT cause vasoconstriction but does cause significant CNS effects.
- Overusing simple analgesics for frequent attacks and precipitating medication overuse headache.
- Forgetting that anti-emetics like metoclopramide and prochlorperazine are dopamine blockers and can cause medication-induced parkinsonism.
- When a known migraineur says 'this headache is different,' don't reflexively treat as migraine — believe them and rule out SAH, meningitis, or other emergencies.
- Confusing gepants and ditans: gepants block the CGRP receptor, while ditans are 5-HT1F agonists.
Clinical pearls
- Match the abortive to severity: analgesics for mild-moderate, triptans for moderate-severe.
- In a migraineur with cardiovascular risk who can't take triptans, a gepant or ditan avoids vasoconstriction.
- Sumatriptan is a shared abortive between migraine (oral/other routes) and cluster headache (subcutaneous).
- Anti-emetics do double duty in migraine: symptom control plus a possible intrinsic anti-migraine effect.
Frequently asked
Why are triptans contraindicated in coronary artery disease?
Triptans abort migraine partly by constricting cranial vessels; this vasoconstrictive action can also affect coronary vessels, making them contraindicated in patients with CAD.
How do gepants differ mechanistically from triptans?
Gepants (ubrogepant, rimegepant) are CGRP receptor antagonists that block the action of CGRP, whereas triptans constrict cranial vessels and inhibit CGRP release. Gepants provide a non-vasoconstrictive alternative to triptans.
What makes lasmiditan (a ditan) useful, and what is its downside?
Lasmiditan is a 5-HT1F agonist that aborts migraine without causing vasoconstriction, an advantage when vascular risk is a concern. Its downside is prominent CNS effects.
Which acute agents are first-line for mild-to-moderate versus moderate-to-severe migraine?
Simple analgesics (aspirin, NSAIDs, acetaminophen) are first-line for mild-to-moderate attacks; triptans (sumatriptan, rizatriptan) are first-line for moderate-to-severe attacks.
What role do anti-emetics play in acute migraine?
Metoclopramide and prochlorperazine control the nausea and vomiting of migraine and serve as useful adjuncts; they may also have an intrinsic anti-migraine effect.
What is the risk of using simple analgesics too frequently?
Frequent analgesic use can transform episodic headache into medication overuse headache (chronic daily headache). Treatment is withdrawal of the offending agent.
Why is CGRP central to modern migraine therapy?
During trigeminovascular activation, the trigeminal nerve releases CGRP, causing neurogenic inflammation of meningeal vessels. Because CGRP is a key mediator, gepants (receptor antagonists) and triptans (which inhibit CGRP release) target this pathway.
Turn this into reasoning you can use on exam day — practice Acute Treatment Options for Migraine on branching cases where your decisions shape the patient.