Acute Migraine Medications
Medication | Dose range | Labs / monitor/notes | Side effects |
Sumatriptan (abortive treatment for episodic or frequent migraine and can help with cluster headaches) Can combine with NSAID |
Nasal: 5mg or 20mg sprayed in the ipsilateral nostril at onset of the headache; may repeat once after 2 hours; onset 10-15 min
SQ: 3/4/6 mg SC; max is 6 mg/dose up to 12 mg ove 24 hrs, may repeat dose once; onset 10 min
PO: 25-100 mg PO x1, may repeat 1x after 2 hr (max 200 mg);onset 30-60min; can take with 500mg Naproxen
|
Caution with patients with CV disease and HTN and patients taking antidepressants (serotonin syndrome)
Short acting esp nasal and SQ form |
**nasal also helps with cluster headache prevention
may initially cause flushing, dizziness, weakness, nausea, drowsiness, stiffness, or feelings of tingling, heat, fatigue
|
Rizatriptan/Maxalt |
5/10mg : Max 30mg/day. Take at the beginning of HA pain
CHILDREN: <88lbs, 5mg; >88lbs,10mg
Menstrual: with or w/out NSAID |
DDI: SSRI, St Johns wort, MAOI, Propranolol
To avoid rebound HA do not use more than 10 days/mo. |
|
Naratriptan |
1-2.5 mg PO; max 5 mg, may repeat once after 4 h
Menstrual b/c 24 hr effect |
Caution with patients with CV disease and HTN and patients taking antidepressants (serotonin syndrome)
This is long acting w/lower risk of recurrence but takes 2 hrs to kick in |
|
Lasmiditan – serotonin agonist; new version of triptan | 50mg, 100mg, 200mg One as needed NO repeat dose |
Driving caution for 8 hr, controlled substance, potential for serotonin syndrome and medication overuse headache Avoid in pregnant women |
Side effects: dizziness sedation/fatigue, nausea, paresthesia |
Ubrogepant (CGRP inhibitor) abortive HA not contraindicated in CVD or MOH HA, can take with an NSAID | 50 mg or 100 mg , repeat 2 hours PRN, max 200 mg/day | Can only use for 8 migraine attacks/month |
Side effects: nausea, somnolence, dry mouth
Caution in patients w/liver disease – lower dose to 50 mg
Avoid use wth CYP4A inhibitors
|
Rimegepant |
75mg ODT Single dose, no repeat LTS study max monthly =15 migraine attacks/month |
**Gepants are effective n those for whom triptans failed and effective for acute and preventative treatment NOT contraindicated in patients with CV NO MOH risk! |
Side effects: nausea
Avoid in patients w/poor liver or kidney fxn
|
Metoclopramide/Reglan (antiemetic)
Used to tx GERD |
10 mg/4-8 hr orally | Monitor BP |
Side effects: fatigue, sleepiness, muscle contractions, slurred speech, mood changes, reduce narcotic effects, drug interactions, tardive dyskinesia
May increase prolactin. May have breast swelling, unusual milf production irregular periods, sexual dysfunction Tardive dyskinesia risk is higher if you take this med for longer than 12 weeks. Longer than 12 wks should be avoided. Do not take with other CNS depressants Caution w kidney disease and pregnancy (1st trimester)
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Promethazine/Phenergan (antiemetic)
Blocks histamine, treats allergies |
25 mg/12hrs rectally | Allergy to sulfites | Do not use with other CNS depressants, double vision, drowsiness, dizziness, insomnia, jaundice, tardive dyskinesia, severe nervous system reaction (stiff muscles, tachycardia, confusion) |
Tepper SJ. Acute Treatment of Migraine. Neurol Clin. 2019 Nov;37(4):727-742. doi: 10.1016/j.ncl.2019.07.006. PMID: 31563229.
Mayans L, Walling A. Acute Migraine Headache: Treatment Strategies. Am Fam Physician. 2018 Feb 15;97(4):243-251. PMID: 29671521.