Which medications are commonly considered second-line after NSAIDs for acute episodic migraine?

Prepare for the Pharmacology IV – Headache Therapeutics Test. Review the therapeutic approaches, tackle multiple-choice questions with explanations, and boost your test-taking confidence. Ace your exam with precision!

Second-line options after NSAIDs for an acute migraine are agents that specifically target the trigeminovascular mechanism of the attack: triptans and ergots. Triptans are selective 5-HT1B/1D receptor agonists that cause constriction of cranial blood vessels and inhibit the release of inflammatory peptides like CGRP, quickly reducing headache intensity and accompanying symptoms for many patients. They are used when NSAIDs alone don’t provide adequate relief or when the attack is moderate to severe. If triptans are not suitable or effective, ergot derivatives—such as ergotamine or dihydroergotamine—offer another vasoconstrictive option to abort the attack, though they carry more side effects and stricter contraindications (e.g., vascular disease, pregnancy) and are used less frequently today. Antihistamines do not address the migraine’s underlying neurovascular processes, and antidepressants are typically reserved for prevention rather than acute abortive treatment, which is why they aren’t placed as second-line options for an acute episode.