What medications can be prescribed for migraines?

Medications for Migraine Treatment

For mild to moderate migraines, start with NSAIDs (ibuprofen 400-800mg, naproxen sodium 500-825mg, or aspirin 650-1000mg) as first-line therapy; for moderate to severe migraines or those unresponsive to NSAIDs, use triptans (sumatriptan, rizatriptan, or zolmitriptan) as first-line treatment. 1, 2

First-Line Acute Treatment Options

For Mild to Moderate Migraines

• NSAIDs are the recommended initial therapy 1, 2

  • Ibuprofen 400-800mg every 6 hours (maximum 2.4g daily) 3
  • Naproxen sodium 500-825mg at onset, repeat every 2-6 hours as needed (maximum 1.5g daily) 2, 3
  • Aspirin 650-1000mg every 4-6 hours (maximum 4g daily) 3
  • Combination acetaminophen-aspirin-caffeine (note: acetaminophen alone is ineffective) 1, 3

• Timing is critical: administer NSAIDs as early as possible during the attack, ideally when pain is still mild 2, 4

For Moderate to Severe Migraines

• Triptans are first-line therapy when NSAIDs fail or for severe attacks 1, 2

  • Oral options: sumatriptan, rizatriptan, naratriptan, zolmitriptan 1, 2
  • Subcutaneous sumatriptan 6mg provides highest efficacy (59% complete pain relief at 2 hours) but with higher adverse event rates 2
  • Intranasal sumatriptan 5-20mg for patients with early nausea/vomiting 2
  • Rizatriptan reaches peak concentration fastest among oral triptans (60-90 minutes) 1

• Contraindications to triptans include: uncontrolled hypertension, coronary artery disease, ischemic vascular conditions, vasospastic coronary disease, basilar or hemiplegic migraine 1, 3

Adjunctive Antiemetic Therapy

Antiemetics should not be restricted to patients who are vomiting—nausea itself is one of the most disabling symptoms and warrants treatment 1, 2

• Metoclopramide 10mg IV or orally, given 20-30 minutes before or with analgesics/NSAIDs 1, 2

  • Provides synergistic analgesia beyond just treating nausea 2
  • Contraindications: pheochromocytoma, seizure disorder, GI bleeding, GI obstruction 1

• Prochlorperazine 10mg IV or 25mg orally/suppository 1, 2

  • Effectively relieves headache pain comparable to metoclopramide 2
  • Contraindications: CNS depression, use of adrenergic blockers 1

Second-Line and Rescue Options

• Dihydroergotamine (DHE) nasal spray or parenteral formulations for severe migraines 1, 2

  • More appropriate than ergotamine for severe attacks 1
  • Contraindicated in pregnancy due to oxytocic effects 5
  • Should not be used chronically due to peripheral vasoconstriction risk 1

• Combination therapy: NSAID plus triptan for patients with inadequate response to monotherapy 2, 4

• Opioids (butorphanol nasal spray, oral opioid combinations) should be reserved only when: 1, 2

  • Other medications cannot be used
  • Sedation effects are not a concern
  • Risk for abuse has been addressed
  • Avoid establishing patterns of frequent opioid use due to dependency risk and medication-overuse headache 2

Intravenous Treatment for Severe Attacks

For severe migraines requiring IV treatment, use metoclopramide 10mg IV plus ketorolac 30mg IV as first-line combination therapy 2

• Ketorolac has rapid onset (approximately 6 hours duration) with minimal rebound headache risk 2
• Prochlorperazine 10mg IV is an alternative to metoclopramide 2
• Caution with ketorolac in renal impairment, history of GI bleeding, or heart disease 2

Preventive Therapy Indications

Consider preventive therapy when: 1, 3

• Two or more attacks per month producing disability lasting 3+ days
• Contraindication to or failure of acute treatments
• Use of acute medications more than twice per week
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction)

First-Line Preventive Medications

• Propranolol 80-240mg daily 1, 3
• Timolol 20-30mg daily 1, 3
• Amitriptyline 30-150mg daily 1, 3
• Divalproex sodium 500-1500mg daily or sodium valproate 800-1500mg daily 1, 3

Critical Pitfalls to Avoid

Medication-overuse headache occurs with acute medication use more than twice weekly—this creates a vicious cycle of increasing headache frequency and daily headaches 1, 2, 3

• Limit acute therapy to no more than 2 days per week 1, 2
• If patients require acute treatment more frequently, transition to preventive therapy rather than increasing acute medication frequency 2

When a triptan fails, try a different triptan before abandoning the class—failure of one does not predict failure of others 2

Select non-oral routes (subcutaneous, intranasal, suppository) when significant nausea or vomiting is present early in the attack 1, 2, 3

Ergotamine derivatives have limited current use due to potential for medication-overuse headaches, ergot poisoning, and negative effects on prophylactic medications 1