Update on Migraine Management

Lisa Larkin, MD, FACP, NCMP, IF


Menopause. 2022;29(5):606-608. 

In This Article

Acute Treatment of Migraine

Early diagnosis of EM and treatment with specific therapies reduces disability by reducing headache duration, severity, and frequency and delays or prevents progression to chronic migraine. For all women with EM, first-line therapy includes identification of triggers and education regarding the importance of diet, sleep, and exercise.

Pharmacologic therapy for acute migraine includes acetaminophen, nonsteroidal anti-inflammatory drugs, ergots, and triptans.[4] Use of opioids or butalbital-containing products should be discouraged because of limited efficacy and potential for medication-overuse headaches, tolerance, and dependence. Triptans, the migraine specific 5-HT receptor agonists, presynaptically act on the TGVS, inhibit the release of CGRP, are highly effective, and are first-line pharmacologic therapy for most patients. There are now seven FDA-approved trip-tans, all with low-cost generic formulations, including oral, nasal, and subcutaneous preparations. All the short-acting triptans (sumatriptan, almotriptan, eletriptan, rizatriptan, and zolmitriptan) are similar in efficacy, speed of onset, and duration of action. Early treatment is key, and treatment failures are often because of late administration, incomplete absorption, or an inadequate dose. Contraindications to triptan use include coronary artery disease or hypertension, hemiplegic or basilar migraine, pregnancy, and use of ergots within 24 hours.

FDA has now approved three medications for acute migraine treatment that affect CGRP. Two of these medications, called gepants (rimegepant and urogepant), are highly specific small-molecule CGRP antagonists that block the CGRP receptor.[4] Both are effective and well tolerated and begin to reduce migraine pain within 60 minutes, although they appear to be less effective than triptans. The third, lasmitidan, is a 5-HT1F receptor agonist that selectively binds to 5-HT1F receptors on trigeminal neurons and inhibits pain pathways. All three medications can be used in patients with vascular disease. It is appropriate to consider one of the gepants or lasmitidan as abortive therapy for patients who fail or are intolerant of triptans.