Acute and prophylactic treatment of migraine: practical approaches and pharmacologic rationale

The antimigraine efficacy of many drugs may be mediated less through their primary modes of action than through the common pathway of serotonergic transmission stabilization. Migraine treatment may be symptomatic, acute/abortive, or prophylactic. Because oral drug absorption is impaired during attacks, parenteral agents are more appropriate for acute therapy. Acute agents include ergots and ergotamine derivatives, narcotics, and sumatriptan succinate. Agents that activate the 5-HT3 receptors must be administered with an antiemetic. Sumatriptan succinate, a specific 5-HT1 receptor agonist, does not necessitate adjunctive antiemetics. Stabilization regimens, such as those using valproate, may favorably alter the natural history of migraine. Sumatriptan succinate is appropriate both for acute attacks and for symptomatic management during stabilization. beta-Blockers, tricyclic antidepressants, and calcium antagonists may be used prophylactically.