Migraine Treatments

There are many available migraine treatments, and they are best started as rapidly as possible. Indeed, if you are someone who knows, through various symptoms (including an aura), that you are about to have a migraine - then treatment should begin at this point. The goal should be to do whatever may be necessary to avoid the head pain starting at all or at least to rapidly eliminate it when it occurs. Once a migraine headache has become 'revved up' or is allowed to 'build up' it is much harder to eliminate, and indeed may be impossible to eliminate until it has run its course - which could mean days of headaches and incapacitation.

Everyone is different, in terms of how they experience their migraine and in terms of what migraine treatments will work for them. For some, there are early warning signs or mild symptoms (neck pain and shoulder pain) which might give a person time to retreat to a quiet environment and relax, to drink a caffeinated beverage, or even to take a short nap. For a few, this may be enough to prevent onset of the migraine itself.

Many patients get a warning but have realized through experience that medications are needed. For still others, the onset of headache occurs rapidly - or even awakens them from sleep after it has become 'full blown' - and little but medications will help.

The key is to experiment with various treatments until you find something that consistently eliminates your headaches.

Medications

Over-the-counter medications should be tried for migraine, since if they consistently work, more expensive prescription medications won't need to be used. Acetaminophen (Tylenol), and NSAIDS (naproxen [Aleve, Naprosyn] ibuprofen [Motrin, Advil]) can be tried. Sometimes these can be combined with a caffeinated beverage and relaxation with excellent results. Migraines sometimes respond to certain prescription combination medications such as Fioricet (butalbital with caffeine and acetaminophen) or Fiorinal (butalbital with caffeine and aspirin).

Triptans

The next level of treatment, and typically the most effective medications for migraine, are the triptans. These medications directly affect the mechanism of migraine (stimulating the serotonin receptors), which is why they are so effective. Triptans (Maxalt, Axert, Relpax, Frova, Amerge, Imitrex, Relpax) can sometimes cause or exacerbate nausea, and so they can be combined with anti-nausea medicatons (Reglan, Phenergan, or Compazine). These anti-nausea medications themselves help with the migraine, although their primary drawback is that they cause sleepiness.

Because each triptan affects slightly different brain receptors, if one is not effective, it is worth trying others, since the difference in response from one triptan to another can be dramatic.

Very powerful, among migraine treatments, if other triptans fail to provide adequete relief, is a subcutaneous (SQ) Imitrex injection. This is a prepackaged needle which allows patients to easily give themselves an injection just below the skin. It is available in 4mg and 6mg doses. The medication works very quickly - so it is the only exception to the rule of treating migraine as early as possible. Patients who experience an aura followed by a headache are encouraged to wait for the actual headache before using Imitrex SQ injections.

Combination Therapy

If a triptan alone works partially, but the headache persists - then it is worth combining medications. There are countless options in this regard, but adding an NSAID would be my choice. For example, if a patient responds only partially to Imitrex 100mg tablets - I would have the patient add 800mg of ibuprofen or 500mg of naproxen. If this is still not sufficient they could consider taking the combination of TRIPTAN + NSAID + anti-nauseant (for example: Imitrex 100mg + naproxen 500mg + Reglan 10mg).

Ergotamines

Ergotamines are an older class of medication among migraine treatments- but if triptans are not effective, then I will often prescribe them. Migranal Nasal Spray is very easy to administer. It takes advantage of rapid absorption through the nasal mucosa. If there is associated nausea, then an anti-nausea medication can be added. There are tablets ergotamine-containing tablets (Cafergot and others) and ergotamine/caffeine suppositories available. Suppositories are very useful for rapid absorption.

Narcotics

I tend to avoid prescribing narcotics, if I can, since they have the potential for abuse (a patient using them to feel 'high' or selling them to others). Some patients, though, are in the unfortunate position of not responding to other medications and therefore greatly benefit from having this option. There are many kinds of narcotics. Pill forms are usually tried first, or a nasal spray (Stadol) with injectable medications used as a last, and very rare, resort.

Other Options

There are other medications that are used by headache specialists to treat an acute migraine. This includes other anti-inflammatories (Toradol, diclofenac), muscle relaxants (Soma, Flexeril, Zanaflex, Robaxin), Benadryl, Neurontin and others. In addition, there are many injectible medications discussed in the section on treating status migrainosus.

Avoid Rebound Headaches

For any medication, including caffeine, it is important to limit use to no more than three days per week. This means it is ok to use the medication multiple times per day, but there should be, on average, at least four days per week when no medication is being used to treat a headache. See this page regarding rebound headaches to learn more.

Special Circumstances

For treatment of daily headaches (which includes migraine treatments for daily migraine) please see treating chronic daily headache.

Click on status migrainosus to review migraine treatments aimed specifically at a migraine that has been ongoing for more than 72 hours.

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