Understanding Migraine Medications
Dr. Rebecca Michael touches on the differences between acute and preventive treatments for migraine
There are two primary forms of treatments for migraine: acute and preventive medications. Acute medication is used during a migraine attack to relieve pain and to stop the migraine from progressing, says Dr. Rebecca Michael, an assistant professor in the Department of Neurology at the University of California, San Francisco. Preventive medication, on the other hand, is taken every day to reduce the frequency and severity of migraine attacks.
Dr. Michael spoke with us about the two forms of medication, and how patients can create an effective migraine treatment plan with their physician.
Acute medications are taken on an as-needed basis at the first sign of a migraine attack. Once a patient suspects an impending migraine attack, he or she can take an acute medication to stop the migraine as early and quickly as possible.
There are three different classes of acute migraine medication:
These include over-the-counter pain relief medications, like ibuprofen and acetaminophen, as well as prescription pain relief medications, like opioids. Dr. Michael recommends over-the-counter analgesics for patients experiencing mild migraine symptoms.
These are migraine-specific medications. There are seven different triptans that are all available as tablets, while one (sumatriptan) is available as an injection, some (sumatriptan, zolmitriptan) as a nasal spray, and others as an oral dissolving tablet (zolmitriptan, rizatriptan). “Triptans, which have been specifically designed to treatment migraine, can be more effective for more moderate to severe migraine attacks or in those who have not responded adequately to analgesics,” Dr. Michael says.
These drugs are not used commonly, and are typically reserved for patients who don’t respond to analgesics or triptans, Dr. Michael says. Migranal and Ergomar are both ergot alkaloids. Dihydroergotamine is also used by specialists as an injection or intravenous infusion in patients with attacks that are not responsive to usual medications.
Acute medication should not be used more than 10 days per month, Dr. Michael says, or a patient will be at risk for medication-overuse headache, also known as rebound headache. Consult your health care provider or a headache specialist if you suspect that your current pain medicine is exacerbating your migraine symptoms.
“Preventive medications are often used for people who are having more than four migraine attacks a month, or if your attacks are very disabling,” Dr. Michael says. These medications are taken daily if they are oral tablets/capsules, monthly or every three months if they are injected.
There are three categories of preventive medication:
These drugs treat high blood pressure, as well as migraine. Beta blockers, calcium channel blockers and angiotensin receptor blockers (candesartan) are forms of antihypertensive drugs used for migraine prevention.
Certain anticonvulsants (anti-seizure medications) can prevent migraine. Topiramate (Topamax®) is a commonly used anticonvulsant for migraine prevention.
In addition to treating depression, antidepressants—such as amitriptyline and venlafaxine—can be an effective preventive treatment for migraine.
Other preventive medications include:
An approved treatment for chronic migraine (>15 headache days per month). It is injected into head and neck muscles every three months.
A newly approved monoclonal antibody that targets a protein (CGRP) receptor. It is a subcutaneous injection that is administered once per month.
Creating a Migraine Treatment Plan
Patients should meet with their health care provider to figure out which treatment options are right for them. An individual treatment plan will primarily depend on the frequency and severity of the patient’s migraine.
“If you’re experiencing more than four migraines a month or if they’re very disabling, you should be on both a preventive and an acute medication for breakthrough attacks,” Dr. Michael says. “If you’re experiencing a migraine once a month or once every few months, then you could consider just an acute medication.”
Dr. Michael says a patient’s complete medical history will also be taken into consideration. Some migraine medications can’t be used when certain medical conditions are present, such as kidney disease and heart disease. In addition, Dr. Michael says patients should tell their doctor about any past allergies they’ve had, as well as whether they are pregnant or plan on becoming pregnant.
After a patient has been on a new treatment plan for at least two months, his or her health care provider can determine whether it’s working.
“For the acute medications, we like to see a patient have pain relief or return to function within two hours after you take the medication,” she says. In addition, doctors will analyze how well the patient is responding to the medication 24 hours after taking it. “Does the migraine come back? Do you have significant pain again in four to six hours? That would be a sign that your acute medication might not be working as well as it should.”
Consulting a Headache Specialist
Because of the numerous forms of medication that exist for the treatment of migraine, Dr. Michael says the best thing a patient can do is consult a headache specialist.
“The best way to manage migraine is to work closely with a headache specialist to come up with a clear acute and preventive plan,” she says.
Dr. Michael advises patients to bring a list of prior medications they’ve tried, the dosage or each, and the length of time they were taken, to their appointment so that their headache specialist will have a better picture of what has and hasn’t worked in the past.