What medications are used to treat migraines?

Migraine Medications

For most patients with migraine, NSAIDs (aspirin, ibuprofen, naproxen sodium, or acetaminophen-aspirin-caffeine combination) are first-line treatment, with triptans reserved for moderate to severe attacks or when NSAIDs fail. 1

First-Line Acute Treatment

Mild to Moderate Migraine

• NSAIDs are the initial treatment of choice with the strongest evidence for aspirin, ibuprofen, naproxen sodium, and the acetaminophen-aspirin-caffeine combination 1, 2
• Acetaminophen alone is ineffective and should not be used as monotherapy 1
• These agents should be taken early in the attack for maximum effectiveness 2, 3

Moderate to Severe Migraine

• Triptans are first-line therapy when NSAIDs fail or for attacks that are initially severe 2, 4
• Oral triptans with proven efficacy include sumatriptan (25-100 mg), rizatriptan, zolmitriptan, and naratriptan 1, 2
• Sumatriptan 50 mg or 100 mg are more effective than 25 mg, with the 50 mg dose having fewer adverse events than 100 mg 5
• Subcutaneous sumatriptan 6 mg provides the most rapid and effective relief (59% pain-free at 2 hours vs 15% with placebo), ideal for severe attacks or when rapid relief is needed 2, 6

Route Selection Based on Symptoms

When significant nausea or vomiting is present, use non-oral routes 1, 4:

• Subcutaneous sumatriptan 6 mg (most effective, 10-minute onset) 7, 6
• Intranasal sumatriptan 5-20 mg 2
• Intranasal dihydroergotamine (DHE) 1
• Rectal sumatriptan 25 mg 6

Antiemetic Therapy

Antiemetics should be used even when nausea is present without vomiting, as nausea itself is highly disabling 2:

• Metoclopramide 10 mg IV provides both antiemetic effects and synergistic analgesia 2, 4
• Prochlorperazine 10 mg IV effectively relieves both headache and nausea 2, 4

Emergency Department/Urgent Care Treatment

For severe migraine requiring parenteral therapy, use IV metoclopramide 10 mg plus IV ketorolac 30 mg as first-line combination 2:

• Ketorolac has rapid onset with 6-hour duration and minimal rebound risk 2
• Avoid opioids due to dependency risk, rebound headaches, and questionable efficacy 2, 3

Critical Contraindications

Triptans must not be used in patients with 1, 4, 8:

• Uncontrolled hypertension
• Coronary artery disease or risk factors for heart disease
• Basilar or hemiplegic migraine
• Peripheral vascular disease
• Recent use (within 24 hours) of ergotamine or another triptan
• Recent use (within 2 weeks) of MAO inhibitors

Medication-Overuse Headache Prevention

Limit acute treatment to no more than twice weekly to prevent medication-overuse headache 1, 2, 4:

• This applies to all acute medications including NSAIDs, triptans, opioids, and combination analgesics 1
• If patients require acute treatment more frequently, initiate preventive therapy 1, 2

Preventive Therapy Indications

Consider preventive medications when patients have 1:

• Two or more migraine attacks per month causing disability for 3+ days
• Use of acute medications more than twice weekly
• Failure of or contraindications to acute treatments
• Uncommon migraine conditions (prolonged aura, migrainous infarction, hemiplegic migraine)

First-line preventive agents include 1:

• Propranolol 80-240 mg daily
• Timolol 20-30 mg daily
• Amitriptyline 30-150 mg daily
• Divalproex sodium 500-1500 mg daily
• Sodium valproate 800-1500 mg daily

Common Pitfalls to Avoid

• Never delay triptan administration until pain is severe; early treatment when pain is mild is significantly more effective 2, 6
• Do not use acetaminophen alone as it is ineffective for migraine 1
• Avoid establishing patterns of frequent opioid use as this leads to medication-overuse headache and dependency 2, 3
• Do not restrict antiemetics only to vomiting patients; nausea alone warrants treatment 2
• Screen for cardiovascular risk factors before prescribing triptans to avoid serious cardiac events 1, 8