​Abortive Medication Treatment for Migraine

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Abortive Medications to treat migraine are designed to abort or stop an attack, hopefully, within 30-60 minutes.  There are several medications that can be used from over the counter preparations to prescription medications:

• NSAID’s – Non steroidal anti-inflammatory medications such as Naproxen, and Ketorolac have been shown to be effective in the abortion of a migraine attack.  Care should be taken to prevent overuse and development of “rebound” headaches.  There are several prescription NSAID's FDA approved for treatment of migraine - Cambia powder (diclofenac), Sprix nasal spray (Ketoralac), Elyxyb oral solution (Celcoxyb)
• Compound preparations such as Goody powders, BC powders, Excedrin Migraine – which contain caffeine – are also common but must be used sparingly to prevent medication overuse (rebound) headaches
• Triptans – prescription medications such as Sumatriptan (Imitrex), Rizatriptan (Maxalt), Naratriptan (Amerge), etc. are effective but should be limited to no more than 2-3 times per week to prevent rebound headaches.  They are contraindicated in patients with Cardiovascular disease such as stroke.
• Ergotamines – Migranal, Trudhesa, DHE, Ergomar – effective but cannot be used within 24 hours of a Triptan and are also contraindicated in patients with cardiovascular disease
• CGRP antagonist – Ubrelvy, Nurtec, and Zavzpret – new on the horizon since 2020, these medications are a small molecule version of the CGRP monoclonal antibodies that are designed to block the release of this inflammatory protein and abort an acute migraine
• 5HT 1F receptor blocker – Reyvow – new category of abortive medication which works similar to Triptans without the cardiovascular risk factors

Preventive Medication Treatment for Migraine

For those migraneurs who are considered “high frequency” Episodic (8-14 days per month) or Chronic (more than 14 days per month), a preventive medication may help to decrease frequency and duration of migraines and limit use of abortive medications which can lead to medication overuse headaches.  There are several categories of medications that have been shown to be beneficial in the prevention of migraine:

• Antidepressant medications – Amitriptyline, Nortriptyline, Venlafaxine, etc.
• Anti-seizure medications – Topiramate (Topamax), Pregabalin (Lyrica), Divalproex (Depakote), etc.
• Antihypertensive medications – Propranolol, Metoprolol, Nadolol, Verapamil, Candesartan, Lisinopril, etc.
• CGRP monoclonal antibodies – Aimovig, Ajovy, Emgality, Vyepti (monthly and quarterly intramuscular injections or IV infusion)  FDA approved since 2018 – this new class of medications have been “life changing” in their ability to reduce the frequency and severity of migraine attacks as well as decrease Cluster headache attacks.  They have very few side effects when compared to the categories listed above 
• CGRP antagonist - Qulipta was FDA approved in 2021 for prevention of Episodic Migraine,  It functions by blocking the CGRP protein from attaching to receptors to prevent migraine attacks.  It is the only once-daily preventive ORAL receptor antagonist

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CGRP pathway monoclonal antibodies

​The first preventive medication dedicated to treating migraine.
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These are the newest preventive medicines specifically developed and licensed for the treatment of migraine. Most of the current preventive medicines used to treat migraine have been developed for other conditions. This is therefore an exciting development for migraine sufferers.

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CGRP pathway monoclonal antibodies

​How they work
Migraine is a brain disorder. During a migraine attack the cerebral nerves and blood vessels release substances including Calcitonin Gene-Related Peptide (CGRP). CGRP is a neuropeptide and has been implicated in different pain processes, including migraine. CGRP also functions as a vasodilator — that is, it relaxes blood vessels.

​Research suggests that these substances are released during a migraine attack and play a significant role in developing and sustaining migraine.

​CGRP compounds	AIMOVIG Erenumab  (Novartis/Amgen)	​AJOVY Fremanezumab  (Teva)	EMGALITY Galcanezumab  (Eli Lilly)	VYEPTI Eptinezumab (Lundbeck)
FDA Approval	​Episodic and Chronic Migraine	Episodic and Chronic Migraine	Episodic and Chronic Migraine Episodic Cluster Headache	​Episodic and Chronic Migraine
​How it is administered	​Subcutaneous injection once per month	​Subcutaneous injection once per month or every three months	​Subcutaneous injection once per month	​Intravenous infusion once every three months

These four new compounds have been developed to either inactivate the CGRP molecule by binding to it or to block its receptor, to prevent migraine developing. Recent research conducted in thousands of people with migraine has demonstrated that these compounds are safe and effective in reducing migraine attacks and headache days.
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None of the compounds are to be taken by mouth. This has the advantage of bypassing the gut, with possibly fewer side effects and the convenience of treating monthly or less. Three of these compounds are designed to be given by subcutaneous injection (just under the skin), once per month. The fourth, Eptinezumab is given intravenously (into a vein by infusion), once every three months. The main side effects noted in the studies were associated injection site reactions.