Abortive Migraine Step Therapy

Initial Treatment

The American Academy of Family Physicians recommends starting with oral NSAIDs (ibuprofen 400-800 mg, naproxen sodium 275-550 mg) or aspirin-acetaminophen-caffeine combination for mild to moderate migraine attacks 1, 2, 3
Aspirin-acetaminophen-caffeine combination is recommended with a strong strength of evidence and a number needed to treat of 9 for pain freedom at 2 hours 3
NSAIDs as monotherapy, such as ibuprofen 400-800 mg, naproxen sodium 275-550 mg, or aspirin 650-1,000 mg, can be used for initial therapy 1, 2

The American Academy of Family Physicians recommends escalating to triptans as first-line therapy for moderate to severe migraines or those failing NSAIDs 1, 2, 3
Triptans, such as sumatriptan, rizatriptan, naratriptan, zolmitriptan, eletriptan, and almotriptan, can be used for escalation therapy 1, 2, 3, 4
Gepants, such as ubrogepant or rimegepant, can be used as a newer option with a number needed to treat of 13 for pain freedom at 2 hours 3

The American Academy of Family Physicians recommends using antiemetic adjuncts, such as metoclopramide 10 mg IV or oral, to improve gastric motility and provide synergistic analgesia 1, 4
Prochlorperazine 25 mg oral or suppository can be used to relieve headache pain directly 1, 4

In pregnancy, acetaminophen 1,000 mg is recommended as the safest option for first-line treatment 5
Ibuprofen can be used as a second-line option in the second trimester only 5
Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail 5

Medication should be administered as early as possible after symptom onset to maximize efficacy 2
NSAIDs should be limited to <15 days/month to avoid medication overuse headache 5
Triptans should be limited to <10 days/month to avoid medication overuse headache 5

The 2023 Veterans Affairs/Department of Defense (VA/DoD) guidelines give a “weak‑for” recommendation for the use of ubrogepant and rimegepant as acute migraine therapies, based on systematic reviews that show moderately robust and clinically significant effects (e.g., an NNT of 13 for achieving pain freedom at 2 hours)【6】【7】.

For rimegepant, the VA/DoD guidelines note that it reduces monthly migraine days by approximately 0.8 days, but this reduction was judged not clinically significant, resulting in a “neither for nor against” recommendation for its preventive use【8】【9】.

Both zavegepant (intranasal) and rimegepant (oral ODT) should be limited to no more than 2 days per week (≤10 days per month) to avoid medication‑overuse headache, as stipulated by the VA/DoD guidelines【6】【7】.