What leads you to consider prescribing a nasal spray formulation for the treatment of acute migraine?

Interesting discussion. From my perspective, one of the big choices in the acute treatment of migraine is whether to give an oral or non-oral treatment. Patient preference studies show that oral agents are preferred if they work so I usually start there. Most patients prefer nasal sprays to subcutaneous injections. I agree with Dr. @Dr. First Last on her three reasons for using non-oral agents; the need for speed, prominent nausea and vomiting, and gastric paresis, but I want to elaborate a bit.

The need for speed can simply be a patient's perception that their usually acute medication takes too long to work. Some people who awaken with headaches have rapidly progressive headaches or develop allodynia early and may also need faster onset ag...

I completely agree with the reasons posted by Dr. @Dr. First Last. I usually agree with my longtime friend, Dr. @Dr. First Last; but I have to say that I disagree with him this time.

Certain nasal sprays work more quickly than comparable tablets, such as Zomig nasal spray, which was my favorite way of using a triptan in the past and now. As Dr. Jennifer notes, they can be used more easily, and for someone with nausea or gastroparesis, they definitely work more quickly.

Zomig nasal spray definitely works more quickly than the tablet. In one study, it showed efficacy in 10 minutes compared to placebo and usually works within 15 minutes. Whereas the tablet showed an effect better than the placebo, only at 30 minutes. Speed is quite important t...

Major reasons to consider are:

• Faster onset of action.
• Patients with significant nausea/vomiting who cannot tolerate oral.
• Patients with gastroparesis (due to migraine or other causes) lead to poor absorption of oral medications.

I never prescribe nasal sprays for the abortive treatment of migraine because I am not convinced that any of them are more effective than the corresponding tablets (sumatriptan and zolmitriptan) or similar medications in tablet form (gepants).

I have extensive experience with the liquid dihydroergotamine nasal spray and have never seen the benefit. The lining of the nose is a rather poor surface for drug absorption and dihydroergotamine is a very large and charged molecule; in fact, it is a small peptide.

The dihydroergotamine nasal spray with a special device to administer the medication high up in the nasal cavity, the FDA approved based on pharmacokinetics, not on efficacy. Efficacy data from a randomized, double-blinded, placebo-control...

The only thing I would add to this excellent discussion is the elephant in the room: payors and their restrictive policies regarding access. For many providers, the prospect of prior authorizations and peer-to-peer is daunting and prohibitive in small practices. Until we face this challenge head-on, the use of non-oral treatments, despite the many well-articulated advantages, will remain largely academic.