5-HT1B/1D receptor agonists (triptans) for acute migraine:
- Subcutaneous (SC) route: Sumatriptan, Rizatriptan, Zolmitriptan
- Rapid onset (10–15 min), effective for moderate-severe migraine
- Rationale: Bypasses GI absorption, useful for patients with vomiting or rapid relief needs
- Intravenous (IV) route: Not commonly used for triptans due to limited IV formulations
- Dopamine receptor antagonists (antiemetics) for acute migraine:
- IV/IM options: Metoclopramide, Prochlorperazine, Chlorpromazine
- Provides antiemetic and mild analgesic effects
- Rationale: Useful for patients with nausea/vomiting; can be combined with triptans
- Gepants (5-HT1F receptor agonists) for acute migraine:
- IV route: Ubrogepant (not yet widely available IV)
- Alternative for triptan non-responders or contraindications
- Rationale: No vasoconstrictive effects, safer for CV risk patients
- Dexamethasone (IV/IM): Adjunct for migraine with prolonged pain
- Rationale: Reduces risk of 72-hour migraine recurrence
Key Considerations:
- Triptans: Avoid in CV disease, uncontrolled HTN, or recent stroke
- Antiemetics: Risk of extrapyramidal symptoms (EPS) with metoclopramide/prochlorperazine
- Gepants: No vasoconstriction, but limited IV options currently