Migraine Medication: Treatment & Prevention Guide

What Medications Are Used During a Migraine Attack?

During a migraine attack, the most commonly used medications are triptans (the gold standard for moderate-severe attacks), NSAIDs like ibuprofen or naproxen, and paracetamol for milder attacks. Taking medication early in the attack—before pain becomes severe—significantly improves effectiveness. Anti-nausea medications like metoclopramide can be added if you experience vomiting.

The goal of acute migraine treatment is twofold: to relieve the pain and associated symptoms, and to stop the attack from progressing. The choice of medication depends on several factors including the severity of your attacks, how quickly they develop, whether you experience nausea or vomiting, and your response to previous treatments.

Understanding the different medication options and how to use them effectively is crucial for successful migraine management. Many people with migraine find that their attacks vary in intensity—some may respond to over-the-counter painkillers while others require prescription-strength triptans. Having a stepped approach, where you try simpler treatments first and escalate if needed, can be helpful.

The most important principle in acute migraine treatment is timing. Research consistently shows that medications work better when taken early in the attack, ideally within the first hour of headache onset. This is because migraine causes changes in the digestive system that slow medication absorption, and pain pathways become more difficult to interrupt once fully activated.

Why Early Treatment Matters

During a migraine attack, the stomach essentially "shuts down"—a phenomenon called gastric stasis. This means tablets taken later in an attack are absorbed more slowly and less completely. Additionally, the pain signals in the brain become more established over time, making them harder to interrupt with medication.

Many people make the mistake of waiting to see if the headache will resolve on its own, or hoping it won't become too severe. By the time they take medication, the attack has progressed to a point where treatment is less effective. Learning to recognize your personal warning signs (prodrome) and treating early is one of the most important strategies for successful migraine management.

Medication and Driving

Some migraine medications can affect your ability to drive safely. You may experience drowsiness, dizziness, or blurred vision. Different people react differently to these medications. You are personally responsible for assessing whether you are fit to drive or operate machinery. The migraine attack itself can also affect your vision and reaction time, so consider whether driving is safe regardless of medication.

How Do NSAIDs Work for Migraine?

NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen, naproxen, and aspirin work by blocking cyclooxygenase (COX) enzymes, reducing the production of prostaglandins that cause pain and inflammation. They are often effective for mild to moderate migraine attacks, especially when taken early. A combination of aspirin and caffeine can enhance absorption and effectiveness.

Non-steroidal anti-inflammatory drugs represent the first-line treatment for many people with migraine, particularly those with mild to moderate attacks. These medications work by inhibiting cyclooxygenase (COX) enzymes in the body, which reduces the production of prostaglandins—chemical messengers that promote pain, inflammation, and fever.

The effectiveness of NSAIDs for migraine goes beyond simple pain relief. Research suggests they may also help stabilize blood vessels and reduce the neurogenic inflammation that occurs during migraine attacks. For many people, NSAIDs taken early in an attack can completely abort the migraine.

One particularly effective combination is acetylsalicylic acid (aspirin) with caffeine. The caffeine serves two purposes: it speeds up absorption of the aspirin and appears to have its own pain-relieving properties in migraine. Studies show this combination is more effective than aspirin alone.

Common NSAIDs for Migraine

• Ibuprofen: Available over-the-counter, effective for many people, typical dose 400-800mg
• Naproxen: Longer-acting than ibuprofen, may be helpful for prolonged attacks
• Aspirin: Often used in combination with caffeine for enhanced effect
• Diclofenac: Available in various formulations including fast-acting versions

Side Effects and Precautions

While NSAIDs are generally well-tolerated for occasional use, they can cause gastrointestinal side effects including nausea, stomach pain, and in some cases, ulcers. Long-term or frequent use increases these risks. Some people may also experience kidney problems with prolonged use.

NSAIDs should be used with caution in people with a history of stomach ulcers, kidney disease, or cardiovascular problems. They can interact with blood pressure medications and blood thinners.

Pregnancy and Breastfeeding

NSAIDs should generally be avoided during pregnancy, particularly in the third trimester, as they can affect fetal development and delay labor. If you are pregnant or planning pregnancy, consult your doctor before using NSAIDs. During breastfeeding, small amounts pass into breast milk, but occasional use is generally considered safe—discuss with your healthcare provider if uncertain.

Is Paracetamol Effective for Migraine?

Paracetamol (acetaminophen) can be effective for mild migraine attacks, particularly in people who cannot tolerate NSAIDs. The exact mechanism of action is not fully understood, but it appears to work differently from NSAIDs. It should not be used more than 15 days per month to avoid medication overuse headache. Paracetamol is safe during pregnancy and breastfeeding.

Paracetamol remains a popular choice for migraine treatment, particularly for those who cannot take NSAIDs due to gastrointestinal problems, kidney issues, or cardiovascular concerns. While its exact mechanism of action is not completely understood, it appears to work through different pathways than NSAIDs.

For some people with mild migraine, paracetamol taken early in an attack provides adequate relief. However, evidence suggests it may be less effective than NSAIDs for moderate to severe attacks. The key to success with paracetamol is early treatment—waiting until pain is severe significantly reduces its effectiveness.

Like other acute migraine medications, frequent use of paracetamol can lead to medication overuse headache. If you find yourself needing paracetamol regularly, this is a sign that preventive treatment should be considered.

Overdose Risk

Taking more than the recommended dose of paracetamol does not improve pain relief but significantly increases the risk of serious liver damage. This is particularly important to remember because paracetamol is also present in many combination products (cold remedies, other pain medications). Always check the total daily dose from all sources.

When Paracetamol Is Preferred

Paracetamol is often the medication of choice for pregnant women with migraine, as it has a long safety record in pregnancy. It's also suitable for breastfeeding mothers and for people who cannot tolerate NSAIDs.

What Are Triptans and How Do They Work?

Triptans are prescription medications specifically designed for migraine that work by activating serotonin (5-HT1B/1D) receptors. This causes constriction of dilated blood vessels around the brain and reduces the release of inflammatory substances like CGRP. They are the gold standard treatment for moderate to severe migraine attacks, providing relief in 60-70% of patients within 2 hours.

Triptans represent a breakthrough in migraine treatment because they were the first medications developed specifically for migraine rather than adapted from other uses. They work through a sophisticated mechanism that targets multiple aspects of the migraine process.

During a migraine attack, complex interactions occur between nerves and blood vessels in and around the brain. Blood vessels dilate, inflammatory substances are released, and pain signals are transmitted. Triptans work by activating specific serotonin receptors (5-HT1B and 5-HT1D) which reverses these processes: blood vessels constrict, release of inflammatory chemicals like CGRP decreases, and pain signal transmission is reduced.

One important aspect of triptan use is timing. Triptans should be taken when the headache begins—not during the aura phase if you experience one. Taking a triptan during aura does not prevent the headache and may reduce the medication's effectiveness when headache does develop.

Available Forms of Triptans

Triptans come in several forms to suit different needs:

• Tablets: The most common form, suitable for most attacks
• Orally disintegrating tablets: Dissolve on the tongue, useful when nausea makes swallowing difficult
• Nasal sprays: Faster onset than tablets, good for those with severe nausea
• Injections: Fastest onset, used for severe attacks or when other forms don't work

Finding the Right Triptan

There are several different triptans available, and while they all work through similar mechanisms, there are differences in how quickly they work, how long their effects last, and their side effect profiles. Research shows that if one triptan doesn't work well for you, another might be more effective. It's worth trying different options to find the one that works best for you.

Combining Triptans with Other Medications

Triptans can be combined with NSAIDs for enhanced effectiveness. This combination may provide better relief than either medication alone and can reduce the risk of headache recurrence (when the migraine returns after initial relief). Triptans can also be combined with metoclopramide, which helps with nausea and improves tablet absorption.

Important Precautions

Triptans are not suitable for everyone. They should not be used by people with:

• Cardiovascular disease, including coronary artery disease or stroke
• Uncontrolled high blood pressure
• Certain other conditions affecting blood vessels

Triptans should not be used during the aura phase and are generally not recommended for people over 65 or under 18 (except nasal spray formulations for adolescents). Smoking combined with triptan use increases cardiovascular risks.

Side Effects

Common side effects include fatigue, nausea, dry mouth, chest or throat tightness (usually not heart-related), tingling sensations, and muscle weakness. These typically resolve within a few hours. If you experience concerning symptoms like severe chest pain, seek medical attention.

How Do Anti-Nausea Medications Help Migraine?

Metoclopramide and other anti-nausea medications (antiemetics) help migraine in two ways: they reduce nausea and vomiting directly, and they speed up stomach emptying, which improves absorption of oral medications. When the stomach "shuts down" during migraine, tablets are absorbed poorly—metoclopramide reverses this, making other medications work better.

Nausea and vomiting are common symptoms of migraine, affecting up to 80% of migraine sufferers. These symptoms are not just uncomfortable—they can make oral medication treatment nearly impossible. When you're vomiting, tablets won't stay down long enough to be absorbed.

During a migraine attack, the stomach and intestines slow down dramatically—a condition called gastric stasis. This means even when you're not vomiting, tablets sit in the stomach rather than moving into the intestine where they're absorbed. Metoclopramide works by reversing this: it stimulates the stomach to contract normally and move contents through more quickly.

For people whose migraine medications seem to work inconsistently from attack to attack, adding metoclopramide may help by ensuring more consistent absorption. It can be particularly useful when combined with triptans or NSAIDs.

Metoclopramide is available as tablets (most common for home use) and as an injection (used in emergency departments for severe attacks).

When Should You Start Preventive Migraine Treatment?

Preventive treatment should be considered when you have 3 or more migraine attacks per month, when attacks significantly impact your quality of life despite acute treatment, when acute medications are ineffective or cause intolerable side effects, or when you're at risk of medication overuse headache. Preventive medications typically take 2-3 months to show full effect and aim to reduce attack frequency by 50% or more.

While acute medications treat individual attacks, preventive medications are taken daily (or in some cases, monthly) to reduce the frequency, severity, and duration of migraine attacks. The decision to start preventive treatment is based on several factors including attack frequency, impact on daily life, and response to acute treatment.

The goal of preventive treatment is typically to reduce migraine frequency by at least 50%. Complete prevention of all attacks is rarely achieved, but significant improvement in quality of life is possible for most people who respond to preventive medication.

It's important to understand that preventive medications take time to work. Most need 2-3 months of consistent use before their full effect is seen. Starting a preventive medication and stopping after a few weeks because "it's not working" is a common mistake. Patience and realistic expectations are key.

Preventive Medication Options

Several classes of medications are used for migraine prevention, often adapted from other medical uses:

Beta-Blockers

Beta-blockers, particularly metoprolol and propranolol, are among the most commonly used preventive medications for migraine. Originally developed for cardiovascular conditions, they have proven effective in reducing migraine frequency for many people. The exact mechanism of action in migraine is not fully understood.

When starting beta-blockers, the dose is increased gradually, and when stopping, it must be reduced slowly to avoid rebound effects on blood pressure and heart rate. People with asthma should use beta-blockers with caution as they can affect the airways.

Amitriptyline

This antidepressant is effective for migraine prevention, typically at doses lower than those used for depression. It's particularly useful for people who also experience tension-type headaches or sleep problems. Amitriptyline is usually taken at night as it can cause drowsiness. Common side effects include dry mouth, drowsiness, and constipation. Alcohol can enhance the drowsy effect.

Angiotensin Receptor Blockers

Candesartan, a medication primarily used for high blood pressure, has been shown to be effective for migraine prevention. It's often tried when other preventive medications haven't worked or caused intolerable side effects. It should not be used during pregnancy as it can harm the developing fetus.

Anti-Epileptic Medications

Topiramate and valproate, used primarily for epilepsy, can also prevent migraine. They appear to work by reducing brain excitability. These medications are usually prescribed by neurologists due to their potential side effects. Topiramate can cause weight loss, memory difficulties, and tingling sensations. These medications should not be used during pregnancy. Alcohol tolerance may be reduced.

Botulinum Toxin

For chronic migraine (15 or more headache days per month), botulinum toxin (Botox) injections can be effective when other treatments have failed. The treatment involves multiple injections around the head and neck every 12 weeks.

What Are CGRP Inhibitors and How Effective Are They?

CGRP inhibitors are a revolutionary new class of preventive migraine medications that block calcitonin gene-related peptide (CGRP), a molecule central to migraine pathophysiology. Given as monthly or quarterly self-injections, they reduce migraine frequency by approximately 50% in half of patients. They are particularly valuable when other preventive treatments have failed.

The development of CGRP inhibitors represents the first medications designed specifically for migraine prevention, based on our growing understanding of migraine biology. CGRP (calcitonin gene-related peptide) is a small protein that plays a crucial role in migraine attacks—it's released during attacks and causes blood vessel dilation and inflammation in the brain's covering (meninges).

Three monoclonal antibody medications that target CGRP or its receptor are available: erenumab, fremanezumab, and galcanezumab. These are given as self-administered injections under the skin, either monthly or (for some) quarterly.

Clinical trials have shown that approximately 50% of patients achieve at least a 50% reduction in monthly migraine days. Some patients experience even more dramatic improvements, while others may not respond. The medications are generally well-tolerated, with the most common side effect being injection site reactions.

Who Should Consider CGRP Inhibitors?

CGRP inhibitors are typically considered when other preventive medications haven't worked well enough or have caused intolerable side effects. In some healthcare systems, they may be restricted to patients with chronic migraine (15+ headache days monthly) due to cost. Your doctor will carefully monitor your response to treatment.

How to Use CGRP Inhibitors

These medications come as pre-filled syringes or auto-injector pens that you use to inject under your skin, similar to insulin injections for diabetes. Depending on the specific medication, you'll take one injection monthly or one injection every three months.

Side Effects

The most common side effects are reactions at the injection site—pain, redness, or swelling. Some people experience constipation. Serious side effects are rare, but any new or concerning symptoms should be discussed with your doctor.

How Are Children and Teenagers Treated for Migraine?

Migraine treatment in children follows similar principles to adult treatment but with age-appropriate medications and doses. First-line treatments include paracetamol and ibuprofen. Children over 7 can use aspirin (but not with fever). Triptans are generally limited to nasal spray formulations for adolescents. Early treatment and avoiding medication overuse are especially important in young people.

Migraine is common in children and teenagers, though it often presents differently than in adults. Attacks may be shorter, pain may be on both sides of the head rather than one, and stomach symptoms may be more prominent than headache in younger children.

The principles of treatment are similar to adult treatment: treating early is more effective than waiting, and limiting medication use to avoid overuse headache is important. Children and teenagers may need help recognizing their early warning signs and understanding when to take medication.

Medications for Acute Attacks in Children

• Paracetamol: Safe for all ages with appropriate dosing
• Ibuprofen: Safe for children, often more effective than paracetamol
• Aspirin: Can be used in children over 7 years, but never when fever is present (risk of Reye's syndrome)
• Triptan nasal spray: Approved for adolescents; tablet forms are generally not recommended under 18

Preventive Treatment in Children

Some children with frequent migraines benefit from preventive medication, particularly if they have attacks 3 or more times per month. The decision requires careful consideration of the impact of migraine on school attendance and quality of life, balanced against medication side effects. If acute medications aren't controlling headaches adequately, seek medical advice.

Can Migraine Medications Make Headaches Worse?

Yes, using acute migraine medications too frequently can cause medication overuse headache (MOH), a chronic daily headache that occurs as a paradoxical effect of the very medications meant to treat headache. This typically happens when acute medications are used more than 10-15 days per month. The only treatment is to gradually withdraw from the overused medication, which initially makes headaches worse before they improve.

Medication overuse headache is one of the most common causes of chronic daily headache. It develops when acute headache medications—including over-the-counter painkillers, triptans, and combination analgesics—are used too frequently. The brain adapts to regular medication exposure, and when medication wears off, a headache develops, prompting more medication use in a vicious cycle.

The threshold for developing MOH varies by medication type. Triptans and combination analgesics (especially those containing codeine or caffeine) carry higher risk and should not be used more than 10 days per month. Simple analgesics like paracetamol and NSAIDs have slightly lower risk but should still be limited to 15 days per month maximum.

Recognition is the first step. Signs that suggest medication overuse headache include needing pain medication almost daily, headaches that have become more frequent over time, medications that seem less effective than they used to be, and early-morning headaches that improve temporarily after taking medication.

How to Track Your Medication Use

Keeping a headache diary is valuable for monitoring medication use. Record the date, type of headache, medications taken (type and dose), and whether they helped. This information helps you and your doctor identify problematic patterns before they lead to MOH.

Frequently Asked Questions