Migraine Medications and Treatments

What is a migraine?

A migraine is a neurological condition that causes an intense headache, usually on one side of the head, lasting anywhere from a few hours to several days. Many people experience other symptoms accompanying the headache, such as nausea, vomiting, and sensitivity to light and sound. Approximately 12% of Americans experience migraine headaches, with women being three times more likely than men to get migraines.

There is no cure for migraines; however, there are treatments that may help reduce pain and other symptoms or prevent migraines from occurring. Researchers are also continuing to study novel treatment methods; for example, various clinical trials have been conducted on the use of a smartphone app and neurostimulation at home to relieve pain.

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How are migraines diagnosed?

The exact cause of migraines is not fully understood. Several factors may come into play, such as imbalances in brain chemicals and genetics. Many people who get migraines have at least one family member who also gets migraines.

People who experience migraines may seek medical advice from their family doctor or receive a referral to a neurologist for the treatment of migraines. During the diagnostic process, healthcare providers ask about family history, symptoms, and the frequency of symptoms. During an initial assessment, a healthcare provider may ask questions about your migraine symptoms and health history, such as:

• How often do you have headaches?

• Where is the pain located?

• How long do headaches last?

• Do headaches coincide with your menstrual cycle?

• What other symptoms do you have with the headache?

• Do you know of any family members with migraines?

• What treatments have you used, including over-the-counter medications, and how did they work?

Around 25% of people with migraines also have a symptom before the onset of the headache called an aura. An aura can develop over a period of minutes, last up to an hour, and may cause symptoms such as:

• Visual disturbance, such as seeing bright spots or flashes of light

• Vision loss

• Tingling sensation in arms or legs

• Feelings of weakness or numbness on one side of the face

Once the migraine is gone, people often feel exhausted and disoriented or as if they are in a fog for a few hours to a couple of days. Discussing auras or feeling drained as migraine symptoms with a doctor or healthcare provider is important.

There isn’t a medical test to diagnose migraines. However, your doctor might request a blood test, MRI, or CAT scan to rule out other causes of headaches before making a definitive diagnosis.

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Migraine treatment options

There is currently no cure for migraines. Instead, treatment may help reduce the intensity of symptoms, relieve severe pain or discomfort during a migraine attack, decrease the frequency of headaches, or prevent recurrent episodes. You should seek medical advice about medications if your headaches interfere with your ability to carry out daily activities.

There are two main types of medications for migraines:

• Abortive treatment works to reduce or eliminate an acute migraine headache once it starts. These treatments work best if taken at the first sign of a headache. There are both over-the-counter and prescription medications available for pain relief.

• Preventive treatment, also called prophylactic treatment, is taken daily, even when you don’t have a headache. Preventive medications, which reduce the frequency of headaches, are only available through a prescription; however, some lifestyle changes may help reduce symptoms or the frequency of headaches.

Migraine medications

There are three main types or classes of drugs for the abortive type of medications: NSAIDs, triptans, and ergot alkaloids. These medications are most effective when taken as early as possible to the start of a headache.

NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are available over the counter or in stronger doses as a prescription. They can be effective at relieving mild to moderate migraine pain or discomfort. Certain medications contain a combination of acetaminophen, aspirin, and caffeine, which may effectively treat mild-to-moderate migraine symptoms.

Common NSAID pain relievers include:

• Advil, Motrin (ibuprofen)

• Aleve (naproxen)

• Aspirin (acetylsalicylic acid)

• Excedrin Migraine (acetaminophen, aspirin, and caffeine)

• Indocin (indomethacin)

• Toradol (ketorolac)

Triptans

Triptans act on serotonin receptors, which can help narrow the brain's blood vessels and decrease pain signals. Triptans are prescription drugs available as regular oral tablets, orally disintegrating tablets, nasal sprays, or small injections under the skin. Triptan medicines should not be used by those with high blood pressure or heart disease.

Examples of triptans include:

• Imitrex, Imitrex STATdose, Onzetra, Sumavel, Tosymra, Zembrace (sumatriptan)

• Maxalt, Maxalt-MLT (rizatriptan)

• Zomig ZMT, Zomig (zolmitriptan)

• Axert (almotriptan )

• Relpax (eletriptan)

• Amerge (naratriptan)

• Frova (frovatriptan)

Ergot alkaloids

Ergot alkaloids can be used to treat severe migraines and cluster headaches. They work by constricting blood vessels and reducing inflammation, which may lessen migraine pain. This headache medication can be combined with caffeine, which helps the medicine be absorbed more quickly, thereby providing faster relief. Ergot alkaloids may also reduce nausea and help with relaxation, making it easier to fall asleep. They should not be used by those with high blood pressure or heart disease.

Examples of ergot alkaloids include:

• Ergomar (Ergotamine Tartrate)

• Migranal (Dihydroergotamine Mesylate)

• D.H.E. 45 (Dihydroergotamine Mesylate)

• Cafergot (Ergotamine Tartrate and Caffeine)

• Migergot (Ergotamine Tartrate and Caffeine)

Migraine prevention

Some medications are used to prevent migraine headaches. These medications are generally available with a prescription only. When used appropriately, they may help reduce the frequency of migraine headaches. These medications are taken daily, even when you do not have a headache. Many were designed to treat other conditions, such as epilepsy and depression, but were also found to reduce headaches. The FDA approved three preventive drugs developed specifically for migraines in 2019. Other medications that have been found helpful in preventing migraines include antidepressants, anticonvulsants, and beta blockers.

CGRP antagonists

Three drugs developed specifically for preventing migraines were approved by the FDA in 2019: Aimovig (erenumab), Ajovy (fremanezumab), and Emgality (galcanezumab). These medicines target a protein called CGRP (calcitonin gene-related peptide) in the brain. The CGRP protein can cause inflammation, which is thought to trigger migraines. By blocking this protein, these drugs may help prevent migraines. Compared to older migraine medicines, these CGRP antagonists are processed differently in the body and usually have fewer side effects.

CGRP antagonists are self-injected using a device with a small needle that automatically injects the medicine just under the skin. A benefit of these medications is they only need to be injected monthly or quarterly, depending on the drug. For example, Aimovig and Emgality are administered as a once-monthly subcutaneous injection, while Ajovy can be administered monthly or quarterly.

Antidepressants

In some cases, antidepressants may be prescribed off-label to prevent migraines. Some commonly used antidepressants that may help prevent migraines include:

• Elavil (amitriptyline)

• Effexor XR (venlafaxine)

Anticonvulsants

Only two anticonvulsants are approved for migraine prevention:

• Depakote (divalproex sodium)

• Topamax (topiramate)

Beta blockers

Beta blockers are typically used for heart conditions, such as high blood pressure, and can help reduce the frequency of migraines. These medications include:

• Inderal, InnoPran (propranolol)

• Blocadren, Betimol (timolol)

• Corgard (nadolol)

• Lopressor (metoprolol tartrate)

• Tenormin (atenolol)

Injectables

Botox shots may also help prevent migraine headaches. Botox is available as a prescription drug for people with chronic migraines, which is classified as a migraine on 15 or more days each month with headaches lasting four or more hours each. Botox contains botulinum toxin, which is injected into the muscles around the forehead, temples, and neck, among other areas, to help prevent migraines.

What is the best medication for migraines?

There is no “best” migraine medicine. People react differently to medications, and what is the best medication for one person may not be the right one for someone else. Choosing the best medication for each person depends on several factors, including:

• Other medical conditions a person has

• Other medications currently being used and potential drug interactions

• Potential side effects of a medication

• Response to treatment

• The goal of treatment (acute or preventive)

Some people may need to try different medications and dosages before finding the right treatment. A healthcare provider will help determine the most appropriate dosage based on a person’s overall condition.

The following is a comparison chart to help you understand the most commonly prescribed medications for migraine.

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Best medications for migraines