What migraine medications are safe to use with Warfarin (Coumadin)?

Migraine Medications Safe with Warfarin

Acetaminophen is the safest first-line migraine medication for patients on warfarin, as it does not significantly increase bleeding risk or interact with warfarin's anticoagulant effects. 1

Recommended Safe Options

First-Line: Acetaminophen-Based Therapy

• Acetaminophen alone (1000 mg) is the safest acute migraine treatment for warfarin patients, as it does not appear on the FDA's list of medications that increase PT/INR response 1
• The combination of aspirin-acetaminophen-caffeine is recommended by guidelines for acute migraine but requires increased PT/INR monitoring due to aspirin's antiplatelet effects 2, 1
• Acetaminophen can be combined with a triptan if monotherapy provides inadequate relief 2

Triptans: Generally Safe with Monitoring

• Triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan, naratriptan, frovatriptan, almotriptan) are NOT listed as warfarin interactions in the FDA label and can be used safely 2, 1
• These are recommended as first-line therapy for moderate to severe migraine attacks 2
• Oral, subcutaneous, or intranasal formulations are all acceptable 2
• Limit triptan use to no more than twice weekly to prevent medication-overuse headache 2, 3

CGRP Antagonists (Gepants): Safe Alternative

• Rimegepant, ubrogepant, and zavegepant are not listed as warfarin interactions and represent safe alternatives 2, 1
• Consider these for patients who do not tolerate or have inadequate response to triptans 2

Medications Requiring Extreme Caution or Avoidance

NSAIDs: HIGH RISK - Avoid or Use with Intensive Monitoring

• NSAIDs (ibuprofen, naproxen, diclofenac, aspirin) significantly INCREASE PT/INR and bleeding risk when combined with warfarin 1
• The FDA explicitly lists diclofenac, naproxen, and other NSAIDs as causing increased anticoagulant response 1
• If NSAIDs must be used, require weekly PT/INR monitoring initially, then every 2 weeks once stable 1
• Despite guideline recommendations for NSAIDs as first-line migraine therapy, warfarin creates an absolute contraindication to routine NSAID use 2, 1

Avoid Completely

• Do not use opioids or butalbital for migraine treatment, as recommended by guidelines regardless of anticoagulation status 2
• These medications lead to medication-overuse headache and dependency 2

Critical Monitoring Requirements

When Starting Any New Migraine Medication

• Obtain PT/INR within 3-7 days of initiating any new migraine medication, even those not listed as interactions 1
• The FDA states that "medications of unknown interaction with coumarins are best regarded with caution" and require more frequent monitoring 1
• Continue weekly PT/INR checks for 3-4 weeks, then return to routine monitoring if stable 1

Herbal and Supplement Warnings

• Avoid feverfew, ginkgo biloba, garlic, ginseng, dong quai, and cranberry products, as these increase warfarin's anticoagulant effects 1
• Coenzyme Q10 and St. John's wort DECREASE warfarin effects, requiring dose adjustments 1
• These botanicals are sometimes used for migraine prevention but are contraindicated with warfarin 4, 1

Practical Treatment Algorithm

For Mild to Moderate Migraine

1. Start with acetaminophen 1000 mg at headache onset 2, 1
2. If inadequate response after 2 hours, add a triptan (e.g., sumatriptan 50-100 mg) 2
3. Check PT/INR within one week of starting triptan 1

For Moderate to Severe Migraine

1. Use combination therapy: triptan + acetaminophen from onset 2
2. Consider subcutaneous sumatriptan 6 mg for fastest relief if nausea/vomiting present 2, 3
3. Alternative: gepants (ubrogepant 50-100 mg or rimegepant 75 mg) 2

For Refractory Cases

1. Metoclopramide 10 mg can be added for nausea and provides synergistic analgesia 2, 3
2. Metoclopramide is NOT listed as a warfarin interaction 1
3. Consider preventive therapy if using acute medications more than twice weekly 2, 4

Common Pitfalls to Avoid

• Never assume NSAIDs are safe just because they are guideline-recommended first-line therapy—warfarin changes this recommendation entirely 2, 1
• Do not allow patients to self-medicate with over-the-counter NSAIDs (ibuprofen, naproxen) without explicit discussion of bleeding risk 1
• Avoid the guideline-recommended "triptan + NSAID" combination—substitute acetaminophen for the NSAID component 2, 1
• Do not forget to check PT/INR even when starting "safe" medications, as individual responses vary 1