What medications are available for migraine headaches?

Medications for Migraine Headaches

For migraine headaches, NSAIDs are first-line treatment for mild to moderate attacks, while triptans are recommended for moderate to severe migraines or when NSAIDs fail. 1

First-Line Treatments

Mild to Moderate Migraines

• NSAIDs with proven efficacy include:
  • Aspirin (650-1000 mg) 1
  • Ibuprofen (400-800 mg) 1
  • Naproxen sodium 1
  • Diclofenac potassium 1
• Combination medications:
  • Acetaminophen-aspirin-caffeine combination is effective 1
• Note: Acetaminophen alone is ineffective for migraine treatment 1

Moderate to Severe Migraines

• Triptans (serotonin 5-HT1B/1D agonists) are first-line for moderate to severe attacks 1:
  • Sumatriptan (oral, subcutaneous, intranasal) 1, 2
  • Rizatriptan 1, 2
  • Naratriptan 1
  • Zolmitriptan 1
• Triptans are most effective when taken early in an attack while pain is still mild 1, 3
• Subcutaneous sumatriptan has the most rapid onset of action 1, 3

Second-Line Treatments

• Dihydroergotamine (DHE):
  • Good evidence for intranasal DHE 1
  • Effective for severe migraines 4
• Antiemetics:
  • Metoclopramide (10 mg IV or oral) - treats nausea and enhances absorption 1, 4
  • Prochlorperazine - effective for headache pain and nausea 1, 4

Third-Line/Rescue Medications

• For refractory migraines when other treatments fail:
  • Newer options include ditans (lasmiditan) and gepants (ubrogepant, rimegepant) 1
  • Opioids (limited use) - should be avoided for chronic headaches due to dependency risk 1
  • Butorphanol nasal spray has good evidence for efficacy 1

Important Considerations

Medication Overuse Headache

• Limit acute therapy to no more than twice weekly to prevent medication-overuse headache 1
• Overuse can lead to rebound headaches and increasing headache frequency 1

Contraindications

• Triptans are contraindicated in patients with 1, 2:
  • Ischemic heart disease
  • Uncontrolled hypertension
  • History of stroke or TIA
  • Hemiplegic or basilar migraines
  • Use of MAO inhibitors within past 2 weeks
  • Use of other triptans or ergot derivatives within 24 hours

Route of Administration

• For migraines with significant nausea/vomiting, use non-oral routes 1:
  • Subcutaneous sumatriptan
  • Intranasal sumatriptan or DHE
  • Rectal suppositories

Preventive Treatment

• Consider preventive treatment when 1, 5:
  • Two or more migraine attacks per month with disability for 3+ days
  • Use of rescue medication more than twice weekly
  • Failure of or contraindications to acute treatments
• First-line preventive options include beta-blockers, topiramate, and candesartan 5
• Second-line preventive option: flunarizine (10 mg/day) 5

Treatment Algorithm

1. For mild to moderate attacks: Start with NSAIDs (ibuprofen 400-800 mg or naproxen sodium) 1, 4
2. For moderate to severe attacks or if NSAIDs fail: Use triptans (sumatriptan 50-100 mg orally or 6 mg subcutaneously) 1, 2
3. For attacks with significant nausea: Add antiemetic (prochlorperazine or metoclopramide) and consider non-oral routes 1, 4
4. For refractory attacks: Consider DHE, ditans, gepants, or rescue medications 1