Abortive Headache Medications

Pearls

Take the maximum allowable dosage of prescribed medication at the very earliest sign of headache.
Best Practice: Combine rescue medication with different mechanisms of action (i.e. NSAID + triptan + antiemetic). Rescue medications are more effective if taken together than taken alone.
For patients with significant nausea and vomiting during migraine attacks, prefer non-oral rescue options (e.g., sumatriptan nasal spray or injection) and cotherapy with an antiemetic (e.g., reglan, compazine, zofran).
Limit use of acute treatments (over-the-counter medications, triptans, etc.) to no more than 2 days per week or 10 days per month to prevent medication overuse headache (rebound headache).
Avoid prescribing opioid or butalbital combination medications.
For patients who don't tolerate medications, consider Cefaly (see details below).

Medication Flow Chart

This flow chart is designed to guide you in making the best decision to help your patients stop their headaches. It provides information on headache severity and relative treatment preferences.

Abortive Medication Flow Chart

Combination Medications

Dose	Warnings
2 tablets as a single dose. Maximum: 2 tablets per 24 hours.	Aspirin may increase risk of GI ulcer and bleeding concerns. Acetaminophen may increase risk of hepatotoxicity.

Excedrin is available to patients over-the-counter, while Fioricet and Cafergot require a prescription. These medications are high risk for medication overuse headache.

Dose	Warnings	Common ADEs
1 to 2 tablets every 4 hours as needed; not to exceed 6 tablets daily.	Medication overuse headache (MOH): strongly associated with transformation from episodic to chronic headache, dependance and abuse. Reserve use for patients without alternative options. Limit use to ≤3 days per month to avoid MOH.	Dizziness, drowsiness, sedation, abdominal pain, nausea, vomiting, dyspnea.

Dose	Contraindications	Warnings	Common ADEs
2 tablets at onset. If symptoms persist, administer 1 tablet every 30 minutes PRN, not to exceed 6 tablets per attack/day and do not exceed 10 tablets per week.	Peripheral vascular disease, hepatic or renal impairment, CAD, uncontrolled HTN, strong CYP3A4 inhibitors, pregnancy or women of childbearing age.	Vasoconstriction; avoid use in older adults.	Bradycardia, ECG changes, hypertension, gangrene of skin, myalgia.

Excedrin

Acetaminophen 250 mg, Aspirin 250 mg, Caffeine 65 mg

Fioricet Tablet

Butalbital 50 mg, Acetaminophen 325 mg, Caffeine 40 mg

Cafergot

Ergotamine 1 mg, Caffeine 100 mg

Antiemetics & Other Mechanisms of Action

Metoclopramide

Antiemetic; Dopamine Antagonist; GI Agent, Prokinetic; Serotonin 5-HT4 Receptor Agonist

Dose	Contraindications	Warnings	Common ADEs
Initial: 10 mg once daily as needed. CrCl 10-60: Administer ~50% of usual dose. CrCl < 10: Administer less than ⅓ of usual dose or do not use.	Seizure disorders, mechanical GI obstruction/perforation/hemorrhage, history of tardive dyskinesia or concomitant use of other agents likely to increase EPS reactions.	CNS depression, extrapyramidal symptoms (EPS), hyperprolactinemia.	Dizziness, drowsiness, fatigue, restlessness.

Prochlorperazine

Antiemetic; First Generation (Typical) Antipsychotic

Promethazine

Antiemetic; Histamine H1 Antagonist

Dose	Contraindications	Warnings	Common ADEs
Initial: 5-10 mg every 6-8h as needed. Max: 40 mg/d.	Large amounts of other CNS depressants.	Altered cardiac conduction, anticholinergic effects, CNS depression, extrapyramidal symptoms, orthostatic hypotension.	Hypotension, ECG abnormality, peripheral edema.

Dose	Contraindications	Warnings	Common ADEs
Initial: 12.5-25 mg every 4-6h as needed. Max: 50 mg/d.	Asthma	Respiratory disease (COPD, sleep apnea), seizures, anticholinergic effects, CNS depression, extrapyramidal symptoms, orthostatic hypotension.	Hypotension, bradycardia, CNS depression, extrapyramidal symptoms.

Ergot Derivative (serotonin, noradrenaline & dopamine agonist)

Drug	Dose
Dihydroergotamine (DHE) Nasal Spray	0.5 mg (one spray) into each nostril at the first onset of migraine. May repeat in 15 minutes. Max daily dose=4 mg (4 doses).
Dihydroergotamine (DHE) Injection	1 mg once at the first onset of migraine. May repeat hourly if migraine persists. Not to exceed 3 mg per day or 6 mg per week.

Contraindications	Warnings	Common ADEs
Peripheral vascular disease, hepatic or renal impairment, CAD, history of MI, hypertension, strong CYP3A4 inhibitors, pregnancy, breastfeeding or women of childbearing age.	Vasoconstriction, avoid use in older adults, high risk for medication overuse headache (use of rescue more than 10 days per month).	Nausea, vomiting, hot flash, diarrhea. Nasal spray: local irritation to nose and throat, rhinitis.

Ditans (5HT1F Selective Serotonin Receptor Agonists)

Drug	Dose	Warnings	Common ADEs
Lasmiditan (Reyvow)	Initial: 50 to 100 mg as a single dose. May increase to 100 or 200 mg as a single dose with subsequent attacks if needed. Maximum: One dose per 24 hours.	Schedule 5 controlled substance. Do NOT drive 8 hours after administration.	Dizziness

Gepants (CGRP Receptor Inhibitors)

Drug	Dosage
Ubrogepant (Ubrelvy)	50-100 mg at migraine onset. Can repeat in 2 hours. No more than 200 mg in 24 hours. With weak CYP3A4 inhibitor: initial dose should be 50 mg and a second 50 mg dose allowed 2 hours after if necessary. With a moderate CYP3A4 inhibitor: initial dose should be 50 mg and second dose should be avoided for 24 hours. CrCl 15-29: Max total daily dose 100 mg. CrCl < 15: AVOID.
Rimegepant (Nurtec)	Without drug interactions: 75 mg once every 24 hours as needed at the start of migraine symptoms. With weak-moderate CYP3A4 inhibitors: 75 mg once every 48 hours as needed at the start of migraine symptoms. CrCl < 15: AVOID.

Contraindications	Common ADEs
Strong CYP3A4 inhibitors.	Nausea, GI side effects.

Over-The-Counter Medications

Drug	Dose
Naproxen (Aleve)	Take 500-750 mg once at migraine onset. Take with food. Do not exceed 1,000 mg daily.
Ibuprofen (Motrin, Advil)	Take 800 mg at migraine onset. May take an additional 800 mg every 8 hours as needed for migraine. Take with food. Do not exceed 3,200 mg daily.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Contraindications	Warnings	Common ADEs
Active GI bleed or ulcer, Uncontrolled heart failure, CrCl < 30 mL/min.	Hyperkalemia, increases risk for cardiovascular events, bleeding and acute kidney injury.	Dizziness, heartburn, nausea.

Drug	Dose	Contraindications	Common ADEs
Acetaminophen (Tylenol)	Take 1000 mg once at migraine onset. May take an additional 1000 mg every 6 hours as needed for migraine. Do not exceed 4000 mg daily. Do not exceed 1300 mg per single dose.	Hepatic impairment	Nausea, vomiting

Analgesic Medication

Triptans (Serotonin Receptor Agonists)

Contraindications	Warnings	Common ADEs
CVD (vascular disease, stroke/TIA, prior MI, CAD, ischemic heart disease, ischemic bowel disease, PVD).	Cardiac arrhythmias, cardiac events, ocular events, serotonin syndrome, CNS effects (dizziness, asthenia, drowsiness, tremor, vertigo, dystonia).	Chest tightness, throat discomfort, nausea, dizziness, paresthesia, flushing, tingling sensation, feeling hot.

Drug	Dosage
Sumatriptan Nasal Spray	10 mg once at the first onset of migraine (10 mg in single nostril). May repeat in 2 hours. Max total daily dose is 30 mg.
Sumatriptan Tablet	25-100 mg once at the first onset of a migraine attack. May repeat in 2 hours. Max total daily dose is 200 mg.
Sumatriptan Injection	4 mg once at the first onset of a migraine attack. May repeat in 1 hour if attack does not subside. May increase injection to 6 mg. Max total daily dose is 12 mg.
Rizatriptan	Tablet or Oral Disintegrating Tablet: 5-10 mg once at the first onset of migraine. May repeat in 2 hours. Max daily dose is 30 mg.
Naratriptan (preferred for px with long lasting migraines episodes or episodes that recur despite multiple dosing of rescue medications)	Tablet: 2.5 mg once at the first onset of migraine. May repeat in 4 hours. Mild-mod CKD: Initial 1 mg, Max total daily dose is 2.5 mg. CrCl<15: AVOID/Contraindicated.

Last updated 10/14/24*

Non-Pharmacologic Options

Migraine Treatment Devices

Some patients might be interested in trying a migraine device. Some devices like Relivion, Gammacore, eNeura TMS, and Nerivio, require a prescription. Other devices, such as Cefaly and HeadaTerm 2, are available to patients without a prescription.
Cefaly and HeadaTerm 2 are devices that are FDA-approved for migraine treatment.
- Both devices are non-invasive and non-pharmacologic.
- These devices can be used in conjunction with headache medications or alone.
- These devices do not require a prescription and patients can purchase using their Health Savings Account (HSA) or Flexible Spending Account (FSA).
The devices use an adhesive to temporarily stick to your forehead and deliver electric impulses to the forehead as an approach to reducing headaches.
- Patients can use these devices for both acute and preventative treatment.
Trying Cefaly
- Cefaly typically costs about $400*, which isn't accessible for everyone.
  - CEFALY.com does offer a full refund to patients within 90 days of purchase.* It's safest to confirm this return policy with the vendor before purchasing.
Trying HeadaTerm 2
- HeadaTerm 2 typically costs about $100* and has a 30 day money back guarantee* if patients purchase from Emeterm.com

Abortive Medications List

Abortive Medications List PDF

Consider downloading and saving the following PDF for quick access to this list of first-line abortive medications.

Abortive Headache Medications

Medication Flow Chart

About Headache.Help