Migraine Medication: Complete Guide to Acute & Preventive Treatment

What Medications Treat Acute Migraine Attacks?

Acute migraine treatment includes NSAIDs (ibuprofen, naproxen, aspirin), paracetamol, and triptans (sumatriptan, rizatriptan). The key principle is taking medication early, while pain is still mild. For moderate to severe attacks, triptans are the most effective option, providing pain relief in 60-70% of patients within 2 hours.

Migraine attacks can vary dramatically in severity, duration, and associated symptoms. The goal of acute treatment is to stop the attack as quickly as possible and restore normal function. Understanding which medications are appropriate for different attack severities helps you manage your condition more effectively and reduces the risk of complications like medication overuse headache.

The cornerstone of effective acute migraine treatment is timing. Research consistently shows that medications taken early in an attack, when pain is still mild or moderate, are far more effective than those taken after the headache becomes severe. This is because once central sensitization develops, the pain pathways become more resistant to treatment. Therefore, the general advice is to treat as soon as you recognize a migraine is developing.

Different medications work through different mechanisms, and understanding these can help you and your healthcare provider choose the most appropriate treatment. Some medications work primarily on pain pathways, while others target the underlying vascular and neurological changes that occur during a migraine attack.

Over-the-Counter Pain Relievers

For mild to moderate migraine attacks, over-the-counter (OTC) medications are often effective and are typically the first line of treatment. These medications include non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol (acetaminophen). NSAIDs work by blocking enzymes called cyclooxygenases (COX), which reduces the production of prostaglandins that contribute to pain and inflammation.

Ibuprofen at doses of 400-800mg has good evidence for migraine relief. Aspirin combined with caffeine is particularly effective, as caffeine enhances the absorption and analgesic effect of aspirin. Naproxen is another effective option that has a longer duration of action, which may help prevent headache recurrence. These medications are most effective when taken early and at adequate doses.

Paracetamol (acetaminophen) is a reasonable alternative for those who cannot take NSAIDs due to stomach problems, cardiovascular disease, or other contraindications. However, it is generally considered less effective than NSAIDs for migraine. The mechanism by which paracetamol relieves pain is not completely understood, but it appears to work centrally in the brain rather than peripherally like NSAIDs.

Triptans - The Gold Standard for Moderate to Severe Attacks

Triptans revolutionized migraine treatment when they were introduced in the 1990s. They are selective serotonin (5-HT1B/1D) receptor agonists that work through multiple mechanisms: they constrict dilated blood vessels in the brain, inhibit the release of inflammatory neuropeptides, and block pain signal transmission. These combined effects make them highly effective for stopping migraine attacks.

There are seven different triptans available: sumatriptan, rizatriptan, zolmitriptan, eletriptan, almotriptan, naratriptan, and frovatriptan. While they share similar mechanisms, they differ in onset of action, duration, and side effect profiles. Sumatriptan was the first triptan developed and is available in the most formulations, including tablets, nasal spray, and injection. Rizatriptan and eletriptan tend to have faster onset and higher efficacy rates in some studies.

The choice of triptan often comes down to individual response and practical considerations. If one triptan does not work well for you, another may be effective, as individuals respond differently to different triptans. The formulation also matters: oral tablets are most convenient but may not be absorbed well if you have significant nausea; nasal sprays offer faster onset and bypass the stomach; subcutaneous injections provide the fastest relief but are more invasive.

Triptans should not be taken during the aura phase before headache begins, as they are not effective at this stage and may even prolong the aura. The optimal time to take a triptan is when the headache phase begins, while pain is still mild. If the first dose does not provide adequate relief, you should not take a second dose immediately. However, if the headache returns after initial improvement, a second dose may be taken after at least 2 hours.

Metoclopramide for Nausea and Improved Absorption

Many migraine sufferers experience significant nausea and vomiting during attacks, which not only adds to the misery but also impairs absorption of oral medications. During a migraine attack, the stomach often enters a state of gastric stasis, where its normal emptying process slows dramatically. This means that tablets taken during an attack may not be properly absorbed.

Metoclopramide serves dual purposes in migraine treatment. First, it is an effective anti-nausea medication that works by blocking dopamine receptors in the brain's vomiting center. Second, and equally important, it promotes gastric emptying, which means that other oral migraine medications are absorbed more quickly and effectively. Taking metoclopramide before or alongside a triptan can significantly improve the triptan's effectiveness.

This medication is available as tablets and, in clinical settings, as an injection. It is particularly useful for patients who notice that their migraine medications seem to work inconsistently - this inconsistency is often due to variable gastric absorption during different attacks.

When Should You Take Preventive Migraine Medication?

Preventive medication is recommended if you have 3 or more migraine attacks per month, attacks that significantly impact quality of life, acute treatments are ineffective or contraindicated, or you are at risk of medication overuse headache. First-line preventive options include beta-blockers (metoprolol, propranolol), antidepressants (amitriptyline), and ARBs (candesartan).

While acute medications treat individual migraine attacks, preventive (prophylactic) medications are taken daily or at regular intervals to reduce the frequency, severity, and duration of attacks. The decision to start preventive treatment is based on several factors, including attack frequency, severity, impact on quality of life, response to acute treatments, and risk of medication overuse.

Preventive treatment should be considered when migraines occur three or more times per month, when attacks are particularly severe or prolonged, when acute medications do not work well or cause intolerable side effects, when acute medications are contraindicated (such as triptans in patients with heart disease), or when there is a pattern of escalating acute medication use that puts the patient at risk for medication overuse headache.

It is important to set realistic expectations for preventive treatment. The goal is typically a 50% reduction in migraine frequency or severity, not complete elimination of attacks. Most preventive medications take 2-3 months to reach full effectiveness, so patience is required. Additionally, some trial and error is normal, as different people respond to different medications.

Beta-Blockers for Migraine Prevention

Beta-blockers, particularly metoprolol and propranolol, are among the most commonly prescribed preventive medications for migraine. They were originally developed for cardiovascular conditions but were found to have migraine-preventive effects. The exact mechanism by which they prevent migraines is not fully understood, but they likely work by affecting the neurovascular system and reducing the hyperexcitability of nerve cells.

Metoprolol is typically the first choice among beta-blockers for migraine prevention due to its favorable side effect profile. The dose is usually started low and increased gradually over several weeks. It is important to allow adequate time to assess effectiveness, as the full benefit may not be apparent for 2-3 months.

When stopping beta-blocker treatment, the dose should be reduced gradually rather than stopped abruptly. Sudden discontinuation can cause rebound effects including elevated blood pressure and rapid heart rate. Patients with asthma should use beta-blockers cautiously, as they can trigger bronchospasm.

Amitriptyline and Other Antidepressants

Amitriptyline, a tricyclic antidepressant, is one of the most effective preventive medications for migraine. When used for migraine prevention, it is typically given at much lower doses than those used for depression. The medication is usually taken at bedtime because drowsiness is a common side effect that can actually be beneficial for patients who also struggle with sleep problems.

Amitriptyline works through multiple mechanisms, including effects on serotonin and norepinephrine pathways. It is particularly useful for patients who have both migraine and chronic tension-type headache, or those with comorbid depression or anxiety. The dose is started low (typically 10-25mg) and increased gradually to minimize side effects.

Common side effects include dry mouth, drowsiness, constipation, and weight gain. Alcohol can intensify the sedating effects, so patients should be cautious about drinking while taking this medication. As with beta-blockers, the dose should be reduced gradually when discontinuing treatment.

Angiotensin Receptor Blockers (ARBs)

Candesartan, an angiotensin receptor blocker primarily used for high blood pressure, has been shown to be effective for migraine prevention. This medication offers an alternative for patients who cannot tolerate beta-blockers or antidepressants. The exact mechanism for migraine prevention is not fully understood, but it may relate to effects on cerebral blood vessels.

Side effects can include dizziness and lightheadedness, particularly when first starting treatment or when standing up quickly. These effects are usually temporary and improve as the body adjusts to the medication. ARBs should not be used during pregnancy as they can harm the developing fetus.

Anti-Epileptic Medications

Certain medications developed for epilepsy have proven effective for migraine prevention. Topiramate and valproate are the two anti-epileptic drugs with the strongest evidence for migraine prevention. These medications work by reducing brain excitability through various mechanisms.

Topiramate is notable for often causing weight loss rather than weight gain, which distinguishes it from many other preventive medications. However, it can cause cognitive side effects such as word-finding difficulties and problems with concentration. These effects are dose-dependent and often improve with dose reduction. Valproate is highly effective but has significant concerns in women of childbearing age due to risks to the developing fetus.

These medications should be prescribed by specialists familiar with their use, and patients require monitoring during treatment. Neither should be used during pregnancy or breastfeeding.

What Are CGRP Inhibitors and How Do They Work?

CGRP (calcitonin gene-related peptide) inhibitors are a new class of medications specifically developed for migraine. They work by blocking CGRP, a protein that plays a key role in migraine attacks. Available as monthly or quarterly self-injections (erenumab, fremanezumab, galcanezumab) or oral tablets (gepants), they can reduce migraine days by 50% or more in many patients.

The development of CGRP-targeted therapies represents one of the most significant advances in migraine treatment in decades. Unlike older preventive medications that were discovered serendipitously to help migraine, CGRP inhibitors were specifically designed based on our understanding of migraine biology. CGRP is a neuropeptide that is released during migraine attacks and plays a crucial role in the pain and vascular changes that occur.

There are two types of CGRP-targeted medications: monoclonal antibodies that block either the CGRP molecule itself or its receptor, and small molecule antagonists (gepants) that block the CGRP receptor. The monoclonal antibodies are given as injections either monthly or quarterly, while gepants are available as oral tablets.

Clinical trials have shown that CGRP monoclonal antibodies can reduce monthly migraine days by 50% or more in many patients. They are particularly valuable for patients who have not responded adequately to traditional preventive medications. Unlike many older preventives, CGRP inhibitors tend to work relatively quickly, with some patients noticing improvement within the first month.

CGRP Monoclonal Antibodies

Three CGRP monoclonal antibodies are currently available: erenumab (which blocks the CGRP receptor), fremanezumab, and galcanezumab (both of which block the CGRP molecule itself). All three are given as subcutaneous injections that patients can self-administer at home using pre-filled syringes or auto-injectors.

These medications come as once-monthly or, for fremanezumab, as a quarterly injection option. The self-injection is performed under the skin of the thigh, abdomen, or upper arm. The most common side effects are injection site reactions such as pain, redness, or swelling. Some patients experience constipation.

Because CGRP inhibitors are relatively new, doctors typically monitor patients carefully during treatment to assess effectiveness and watch for any unexpected effects. They are currently approved for patients who experience at least 4 migraine days per month, though access and insurance coverage vary by country and healthcare system.

Gepants - Oral CGRP Receptor Antagonists

Gepants offer an oral alternative to injectable CGRP monoclonal antibodies. Rimegepant and ubrogepant are examples of gepants that can be used both for acute treatment of migraine attacks and, for rimegepant, as preventive therapy when taken every other day. This dual use makes them particularly versatile.

For acute treatment, gepants offer an alternative for patients who cannot use triptans due to cardiovascular contraindications or for whom triptans are ineffective. Unlike triptans, gepants do not constrict blood vessels, making them safer for patients with heart disease.

How Is Botulinum Toxin Used for Chronic Migraine?

Botulinum toxin (Botox) injections are approved for chronic migraine, defined as 15 or more headache days per month with at least 8 having migraine features. Treatment involves injections into 31 sites around the head and neck every 12 weeks. It is typically reserved for patients who have not responded adequately to other preventive treatments.

Botulinum toxin, commonly known by the brand name Botox, has been used for chronic migraine since receiving regulatory approval in 2010. It works by blocking the release of certain neurotransmitters involved in pain transmission. The treatment involves multiple small injections into specific muscles of the forehead, temples, back of the head, neck, and shoulders.

The standard treatment protocol involves injecting 31 sites with a total of 155-195 units of botulinum toxin. The injections are repeated every 12 weeks, although some patients may receive more frequent treatments. Most patients require 2-3 treatment cycles before the full benefit is apparent, so patience is important.

Botulinum toxin is generally well tolerated. The most common side effects are neck pain and temporary weakness of the neck muscles. Some patients experience drooping of the eyelid if the toxin spreads beyond the intended injection sites. These effects are typically temporary and resolve as the toxin wears off.

This treatment is typically reserved for patients with chronic migraine who have not responded adequately to at least 2-3 other preventive medications. It requires administration by a trained healthcare professional and is usually provided through specialized headache clinics.

Can You Take Migraine Medication Too Often?

Yes. Taking acute migraine medications more than 9-10 days per month can lead to medication overuse headache (MOH), where the medications paradoxically increase headache frequency. This applies to all acute medications including triptans, NSAIDs, and paracetamol. If you need medication this often, preventive treatment should be considered.

Medication overuse headache (MOH), previously called rebound headache, is a common and often overlooked problem. It occurs when the frequent use of acute headache medications leads to an increase rather than decrease in headache frequency. The brain becomes dependent on the medication, and headaches occur more frequently as the effect of each dose wears off.

The thresholds for developing MOH vary by medication type. For simple analgesics like paracetamol or NSAIDs, the risk increases when used more than 15 days per month. For triptans and combination analgesics, the threshold is lower at around 10 days per month. The safest general rule is to avoid using any acute headache medication more than 9 days per month.

Recognizing MOH can be challenging because the symptoms are similar to the underlying migraine - indeed, they may initially appear as worsening of the original condition. Clues that suggest MOH include headaches that occur almost daily, headaches that wake you in the early morning, and medication that seems to work less well over time requiring increasing doses or more frequent use.

Treatment of MOH typically requires withdrawal from the overused medication. This process can be challenging because headaches often temporarily worsen during withdrawal. The approach to withdrawal varies - some doctors recommend abrupt cessation while others prefer gradual reduction. Bridge therapy with other medications and sometimes corticosteroids may be used to ease the transition. Preventive medication is usually started simultaneously.

How Is Migraine Treated in Children and Adolescents?

Children can use paracetamol and ibuprofen for acute migraine. Aspirin is avoided under age 16 due to Reye's syndrome risk. Triptans are generally not approved for children under 18 except as nasal spray (sumatriptan, zolmitriptan) for adolescents in some countries. Early treatment and not using medication too frequently are especially important in young patients.

Migraine in children and adolescents presents some unique challenges. Attacks are often shorter than in adults and may have different features, such as bilateral rather than unilateral headache. The approach to treatment shares many principles with adult treatment but requires careful attention to age-appropriate medications and dosing.

For acute treatment, paracetamol and ibuprofen are the first-line options. These should be given early in the attack for best results. Aspirin and aspirin-containing medications should not be given to children under 16 years of age due to the risk of Reye's syndrome, a rare but serious condition affecting the brain and liver.

Triptans in tablet form are generally not approved for use in children under 18, though some countries approve certain triptans for adolescents aged 12 and older. Sumatriptan and zolmitriptan nasal sprays may be options for adolescents in whom standard pain relievers are insufficient. The decision to use triptans in young patients should be made by a healthcare provider experienced in pediatric headache.

Preventive treatment in children follows similar principles to adults but uses lower doses. Non-pharmacological approaches, including lifestyle modifications, stress management, and adequate sleep, are particularly important in the pediatric population. Some children with frequent migraines may benefit from preventive medication, though the evidence base for specific drugs is less extensive than in adults.

What Migraine Medications Are Safe During Pregnancy and Breastfeeding?

Paracetamol (acetaminophen) is generally considered safe throughout pregnancy. NSAIDs should be avoided, especially in the third trimester. Triptans have limited safety data but may be used when benefits outweigh risks. Most preventive medications should be stopped before pregnancy. Always consult your doctor before taking any medication during pregnancy or while breastfeeding.

Managing migraine during pregnancy requires careful balancing of the need to treat the mother's symptoms against potential risks to the developing baby. The good news is that many women experience improvement in their migraines during pregnancy, particularly during the second and third trimesters. However, some women continue to have significant attacks and require treatment.

Paracetamol (acetaminophen) is the safest option for acute migraine treatment during pregnancy and can be used throughout all trimesters. NSAIDs should generally be avoided, and are contraindicated in the third trimester because they can affect fetal kidney function and the circulatory system, and may delay labor.

Triptans have been used during pregnancy, and accumulated data suggests they do not significantly increase the risk of birth defects. However, the data is limited, so they are typically reserved for severe attacks when other options have failed. If you were using triptans before becoming pregnant and your migraines are severe, discuss the risks and benefits with your obstetrician and neurologist.

Most preventive medications should be stopped before conception if possible. Valproate is absolutely contraindicated due to significant risk of birth defects. Beta-blockers may be continued if necessary but require monitoring as they can affect fetal heart rate. The newer CGRP inhibitors do not yet have sufficient safety data for use during pregnancy.

During breastfeeding, paracetamol remains the safest option. Small amounts of other medications pass into breast milk, but for many medications, the amount is too small to significantly affect the baby. Discuss your specific situation with your healthcare provider to weigh the benefits of breastfeeding against any potential medication risks.

Can Migraine Medications Affect Your Ability to Drive?

Some migraine medications can impair driving ability by causing drowsiness, dizziness, or visual disturbances. This is particularly true for preventive medications like amitriptyline and some anti-epileptic drugs. The migraine attack itself may also impair driving. You are responsible for assessing whether you can safely drive while taking medication or during a migraine.

Both migraine attacks and their treatments can potentially impair your ability to safely operate a vehicle. During a migraine attack, symptoms such as visual disturbances (including aura), sensitivity to light, difficulty concentrating, and the pain itself can make driving dangerous. Even after the acute pain resolves, many people experience a postdrome phase where they feel fatigued and mentally foggy.

Several migraine medications can also affect driving ability. Sedating medications like amitriptyline cause drowsiness, especially when first started or when doses are increased. Some anti-epileptic drugs used for prevention can cause drowsiness, dizziness, or cognitive slowing. Even triptans can occasionally cause dizziness or fatigue in some individuals.

There is no blanket rule about driving with migraine medications - the effects vary by individual, medication, and dose. You are ultimately responsible for assessing whether you can drive safely. When starting a new medication, it is wise to avoid driving until you know how the medication affects you. If you feel drowsy, dizzy, or otherwise impaired, do not drive.

How Can Tracking Medication Help Your Treatment?

Keeping a migraine diary that records your attacks, triggers, and medication use helps identify patterns, assess treatment effectiveness, and prevent medication overuse. Record the date, severity, duration, associated symptoms, medications taken, and their effectiveness. This information is invaluable for healthcare appointments.

A migraine diary is one of the most valuable tools for managing your condition effectively. By systematically recording information about your attacks and medication use, you can identify triggers, assess how well your treatments are working, and ensure you are not overusing acute medications.

Your diary should include: the date and time of each attack; pain severity (using a consistent scale like 0-10); location and quality of the pain; associated symptoms such as nausea, light sensitivity, or aura; potential triggers you can identify; medications taken, including doses and timing; and how well the medication worked. Many people find smartphone apps convenient for tracking, though paper diaries work equally well.

Reviewing your diary can reveal patterns you might not otherwise notice. Perhaps your migraines cluster around your menstrual cycle, or are triggered by specific foods or sleep changes. You might notice that a particular medication works well when taken early but not when taken late. This information helps you and your healthcare provider optimize your treatment.

Your diary also helps prevent medication overuse by making your consumption visible. It is easy to underestimate how often you are taking medication, but a written record makes it clear. If you notice you are approaching the 9-day threshold, you can discuss preventive options with your doctor.