Drug therapy for migraine, divided into acute (abortive) and preventive (prophylactic) treatments:
1. Acute
(Abortive) Migraine Treatment
Used during
a migraine attack to relieve symptoms.
a. Analgesics / NSAIDs
- Examples: Ibuprofen, Naproxen,
Aspirin, Acetaminophen
- Best for mild to moderate migraines
- Often combined with antiemetics
(e.g., metoclopramide)
b. Triptans
(1st line for moderate-severe)
- Examples: Sumatriptan, Rizatriptan,
Zolmitriptan
- Mechanism: 5-HT₁B/₁D agonists →
vasoconstriction & reduced neurogenic inflammation
- Avoid with:
- CAD, stroke, uncontrolled
HTN
- Ergotamine (within 24 hrs)
- MAO inhibitors (within 2
weeks for some)
c. Ergot
Alkaloids
- Examples: Ergotamine,
Dihydroergotamine (DHE)
- Older agents, less commonly
used now
- Avoid with: CYP3A4 inhibitors,
pregnancy, triptans
d. Antiemetics
- Examples: Metoclopramide,
Prochlorperazine
- Used for nausea/vomiting and
to enhance absorption of oral meds
e. New options
- Gepants (CGRP antagonists):
Ubrogepant, Rimegepant
- Ditans (5-HT1F agonist):
Lasmiditan
- Good for patients with
cardiovascular risk (no vasoconstriction)
2. Preventive (Prophylactic) Treatment
Used to reduce
frequency/severity of migraines. Indicated if:
- ≥4 migraine days/month
- Debilitating attacks
- Poor response to abortive
meds
a. Beta-blockers
- Examples: Propranolol, Metoprolol
- First-line for many patients
b. Anticonvulsants
- Examples: Topiramate, Valproate
- Topiramate: also causes
weight loss (good in obesity)
- Valproate: avoid in
pregnancy
c. Antidepressants
- Examples: Amitriptyline (TCA),
Venlafaxine (SNRI)
- Good if comorbid depression,
anxiety, or insomnia
d. CGRP
inhibitors
- Examples: Erenumab, Fremanezumab,
Galcanezumab
- Monoclonal antibodies
targeting calcitonin gene-related peptide (CGRP)
- Given monthly (injection)
e. Others
- Botox: for chronic migraine (≥15
days/month)
- Lifestyle: sleep, hydration, stress,
trigger avoidance
Presentation for Drug Therapy for Migraine
END OF THE CHAPTER
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