Migraine pharmacology — abortive & prophylactic

Triptans, ergots, CGRP antagonists, gepants, ditans — and when to switch from abortive to prophylactic.

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◆Abortive (acute attack)

•Step 1: NSAIDs (ibuprofen, naproxen) ± APAP — mild attacks
•Step 2: Triptans (sumatriptan, rizatriptan, eletriptan, etc.) — moderate-severe
•Step 3: Ergots (DHE) — rare, second-line
•Step 4: Gepants (rimegepant, ubrogepant) — CGRP receptor antagonists; safe in CAD/uncontrolled HTN
•Step 5: Lasmiditan (ditan) — 5-HT1F agonist; no vasoconstriction; sedation, can't drive 8 hr
•Antiemetics (metoclopramide, prochlorperazine) — synergize with migraine treatment
•AVOID opioids and butalbital — risk of medication overuse headache + addiction

•Mechanism: 5-HT1B/1D agonist → vasoconstriction + ↓ inflammatory neuropeptides
•CONTRAINDICATIONS: CAD, prior MI, stroke, uncontrolled HTN, hemiplegic / basilar migraine, pregnancy (avoid)
•Side effects: chest tightness ('triptan chest'), flushing, dizziness
•Don't combine with ergots or other triptans within 24 hr
•Don't take >10 days/month → medication overuse headache
•Combinations: sumatriptan-naproxen (Treximet) — synergy

•Gepants (rimegepant, ubrogepant): oral, abortive — safe in vascular disease (no vasoconstriction)
•CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab): IV/SC monthly-quarterly; PROPHYLAXIS
•Atogepant: oral PROPHYLAXIS gepant
•Side effects: constipation (erenumab), injection-site reactions; well tolerated overall

•β-blockers — PROPRANOLOL or metoprolol (best evidence)
•Anti-epileptics — TOPIRAMATE (weight loss bonus; consider in obese), valproate (teratogen — not in women of childbearing age)
•TCAs — AMITRIPTYLINE (good for sleep + tension headache + migraine combo)
•CGRP mAb — erenumab, etc. (newer, expensive, very effective)
•Botulinum toxin (Botox) — chronic migraine (≥15 days/month)
•Magnesium 400–600 mg/day — often added as adjunct

•Pregnancy: APAP first; metoclopramide for nausea; avoid triptans (caution; sumatriptan safest of class); avoid valproate, topiramate, NSAIDs after 30 wks
•Menstrual migraine: triptan or naproxen ×3–7 days starting 2–3 days before period
•Status migrainosus (>72 hr): IV fluids + IV antiemetics + NSAID + DHE; consider steroids
•Hemiplegic / basilar migraine: NO triptans (vasoconstriction risk)

◆Triptans CONTRAINDICATED in CAD, stroke, uncontrolled HTN, hemiplegic/basilar migraine, pregnancy
◆Sumatriptan-naproxen combo > either alone (synergy)
◆Medication overuse headache: triptan/opioid/butalbital use >10 days/mo → vicious cycle
◆Prophylaxis trigger: ≥4 attacks/month or disabling attacks
◆Topiramate prophylaxis = weight LOSS bonus; valproate = AVOID in women of childbearing age (NTD)
◆Botox for CHRONIC migraine (≥15 days/month × 3 months)
◆CGRP mAbs (-mab) are prophylactic; gepants/ditans/triptans are abortive

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