Commonly Used Acute Migraine Treatments

A migraine is an episodic, unpredictable headache disorder that presents with disabling attacks. These migraine attacks can be successfully treated with acute medications. Some of these medications are available over the counter and are prescription medications. Acute medications fall into general classes of medicines including analgesics, ergotamines, and triptans.

Analgesics are considered nonspecific migraine medications as they work on pain systems in general, not just activated pain pathways involved in migraine. For example, if a patient has a sprained ankle and a migraine, an NSAID may help reduce the pain of both conditions. In contrast, triptans and ergotamines are more migraine-specific medications. This means they work on the pain pathways involved in migraine but have no effect on other pain pathways such as those involved in a sprained ankle.

How can you tell you are taking the right medication for your migraine?

You can determine the success of your treatment by asking yourself the following questions:

Are you pain-free in 2-4 hours?

Are you functioning normally in 3-4 hours?

Does your headache respond to treatment consistently at least 50 % of the time?

Are you comfortable with taking the treatment prescribed and still able to plan your day?”

If you answered “No” to one or more of these questions, your treatment should be reassessed.

You can determine the success of your medication by treating as few as two or three headaches and monitoring your improvement, or lack thereof. Comparing two similar headaches with similar results predicts the 3rd headache result with about 70% accuracy.

To avoid continued failure of a given medication, assess whether you wait too long to take yours before treating your headache. Delay in treating your migraine can make it more difficult for your headache to respond to the medication.

For many patients, there is a “window of opportunity” during a migraine where there is an increased chance that the headache will respond to treatment. This window of opportunity occurs within the first two hours following onset of headache pain. This is why physicians work with their migraine patients in teaching them to treat earlier in the course of the attack, and if possible, treat when pain is mild.

Two important considerations when managing migraine:

Make sure the headache is a migraine and

Restrict your use of acute migraine treatment to no more than nine days per month. If you find that you need more acute medication than nine days per month, then migraine prevention therapy is likely needed.

Analgesics & NSAIDs
  • Nonspecific pain medications
  • Readily available as over-the-counter remedies (including aspirin, naproxen sodium, ibuprofen, acetaminophen, among others)
  • Cost affordable
  • May be given as monotherapy or in combination with other agents (eg. acetaminophen, aspirin, and caffeine)
  • Should not be used in patients who have contraindications for using NSAIDs (hyperacidity syndromes such as ulcer, gastrointestinal esophageal reflux disease, the triad of aspirin sensitivity, nasal polyps, and asthma and kidney disease)
  • Regular or even daily use of these medications may make headaches worse due to medication overuse
Ergotamine, Ergot Combinations Ergot Alkaloids (Dihydroergotamine)
  • There are currently several different formulations of ergotamine for the acute treatment of migraine including oral, rectal, or intranasalDihydroergotamine is available as an intranasal, intramuscular, or intravenous treatment
  • May work on more than just activated pathways in migraine
  • Nausea may be a side effect from these medications and also may be part of the migraine itself. Some patients may benefit in taking these agents with another medication to prevent nausea.
Triptans
  • Readily available with prescription
  • Seven different triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan)
  • Available as oral tablets, orally disintegrating tablets, nasal sprays and subcutaneous injection, so you may request a specific formulation if you have a preference.
  • More migraine specific
  • Some patients may find improved response to triptans if they take their medication early in the course of the attack when pain is mild.
  • Common triptan side effects may include tingling, sleepiness, flushing, throat or chest tightness

Oral and Intranasal Triptan Therapy for Acute Migraine Headache
Sphenopalatine Ganglion Blocks in Headache Disorders