Prescription Acute Medications for Migraine
Roger K. Cady, MD
Medications are an important tool to manage migraine. But they need to be used correctly. A person with migraineneeds to know how and when to use a prescription acute medication.Even though there are instructions printed on the bottle and the pharmacist has provided alist of potential side effects, understanding how to make a medication work for you is perhaps the most important point of all. For example, for acute medications (medications taken just when you need to relieve an attack), the label may state that the medication should be taken at the onset of a migraine and not more than 2 days a week. Simple enough until you have to decide, “Is it really a migraine?”“Do I really need to use the prescription medication or will this headache stop after taking aspirin?”“What will I take if the medication does not work?”“What if I need the medication more than 2 days a week?” “Will there be side effects?”
These real life questions must be answered to get the maximum benefit from the migraine medications. Ask your clinician these questions. The answers will help you make successful therapeutic decisions. Over time you will work with theclinician to refine and optimize migraine treatment. The key to success is communicating directly in partnership with your provider.
Understanding the Purpose of Medications for Migraine
Medications for migraine are divided into two groups: acute and preventive. Acute medications are designed to reverse an attack once it has begun. Preventive or prophylactic medications protect the nervous system from the attack of migraine beginning. Another way to think of these medications is that acute medications alter individual attacks of migraine while preventive medications alter the pattern of migraine attacks.
Acute Medications for Migraine
The acute medications for migraine may be non-specific or specific. Non-specific medications are those that treat symptoms of migraine and may also be used for other pain conditions (e.g. narcotic or opioids). Specific medications were developed specifically for the treatment of many or all the symptoms of migraine, and do not work for pain or other symptoms in non-headache conditions.
Non-Specific Prescription Acute Migraine Medications
There are two classes of non-specific medications that are often prescribed for migraine. There are medications that contain barbiturates (e.g. Fiorinal, Fioricet) and those that feature opioids (e.g. Vicodin). As a rule, the use of these medications should be avoided for a number of reasons:
- They are not-specific (they don’t address the mechanisms of migraine).
- They cause sedation and cognitive side-effects.
- They carry an important risk of medication overuse and medication overuse headache (MOH). In other words, they change their receptors in the brain and, if used too frequently, they cause addiction and also precipitate daily attacks of migraine (chronic migraine).
These medications may be useful in special situations, especially if used infrequently.
Specific Acute Migraine Medications;
There are two classes of specific medications that may be used for migraine. The compounds containing ergotamine, and the triptans and certain non-steroidal anti-inflammatory medications (Cambia, Excedrin and Motrin).
Ergotamine compounds are inexpensive medications that are still widely used in some countries for the treatment of severe migraine attacks, but not in the U.S. They are generally regarded as a safe and useful drug when prescribed in the correct dose. However, they are not as effective as the triptans and may have more side effects.
The migraine-specific triptans have revolutionized the treatment of migraine. For patients who experience temporary disability with their migraine, they are usually the drugs of choice to treat a migraine attack in progress. There are 7 triptans in the market. Sumatriptan (Imitrex), zolmitriptan (Zomig), naratriptan (Amerge), rizatriptan (Maxalt), almotriptan (Axert), eletriptan (Relpax) and frovatriptan (Frova). There is also a combination of sumatriptan and naproxen (Treximet). Triptans have been chemically engineered to selectively reverse the process of migraine and there have been many clinical trials that have established effective doses to produce pain-free outcomes within 2 hours of taking the medication.
Who Should not Use a Triptan
Triptans are contraindicated in the presence of active cardiovascular (heart and stroke) diseases. That means that patients that had a heart attack, have angina, had a stroke or a transient ischemic attack, or other vascular problems should not use them. Triptans are also contraindicated for those with uncontrolled hypertension (high blood pressure) (hypertension controlled with medications is not a contraindication), or in rare forms of migraine (e.g. hemiplegic migraine). In pregnancy they may be used if the benefit outweighs the risk, but no triptan is indicated in pregnancy.
Who Should Use a Triptan
A triptan should be used if you have temporary-impairment with your migraine attacks and don’t have contraindications to their use. If migraine sufferers have frequent attacks, they also need preventive medications, but this does not mean that they cannot use triptans.
Which Triptan is Probably Better for Me
It is difficult to identify the best triptan for a particular patient. And it is important to emphasize that if one triptan fails, a second may work. But you should not simply try one triptan after another believing there is a perfect triptan for me.
Triptans are available as oral tablets or melts (wafers), nasal sprays and injections. Most patients prefer an oral formulation that are taken by mouth. They are best used when a migraine can be treated early and the headache is still mild. Sometimes migraine begins with severe nausea or the headache is already advanced. In this case, a nasal spray or injection may be the best choice since it bypasses the digestive system. For patients needing rescue for debilitating migraines, injections may be ideal.
There are two classes of triptans: those that are fast-acting with a short duration (1 ½ hours), and those that are slow-acting with a prolonged duration (8 to 25 hours). Among the fast triptans, we have sumatriptan, rizatriptan, zolmitriptan and almotriptan. The long duration triptans are naratriptan and frovatriptan. Eletriptan seems to be in-between these two classes.
Accordingly, for attacks that are debilitating, fast onset triptans are preferred. For migraines that are prolonged a long duration triptan may be efficient. Alternatively, a fast onset triptan may be combined with a non-steroidal anti-inflammatory medication (NSAID).
Important Issues to Understand about Acute Medications
- Non-specific medications are useful for migraine if they are effective and required infrequently.
- Compounds containing barbiturates and opiates should not be used unless in very specific situations.
- Most patient that need care require a specific medication at least for some of their migraines.
- Most acute migraine medications cause more headaches if they are used too often (e.g. more than 10 days per month). Of course a migraineur should treat attacks to avoid disability. But if they happen too frequently, preventive medications are indicated and should be discussed with your clinician.
- Migraine attacks should be treated early. Do not fight with your migraines. Use your medication early in the migraine process.
Table 1:Non-Specific Migraine Therapies
|Generic Treatment Doses|
|Aspirin tablets||325 mg – 650 mg|
|Acetaminophen tablets||325 mg – 1000 mg|
|Aspirin plus acetaminophen plus caffeine tablets||250 mg plus 250 mg plus 65 mg|
|Isometheptene mucate plus acetaminophen plus dichloralphenazone tablets||65 mg plus 325 mg plus 100 mg|
|Butalbital plus aspirin plus caffeine tablets||50 mg plus 325 plus 40 mg|
|Butalbital plus acetaminophen plus caffeine tablets||50 mg plus 325 plus 40 mg|
|Diclofenac K tablets||50 mg to 100 mg|
|Flurbiprofentablets||100 mg to 300 mg|
|Ibuprofen tablets||200 mg to 1200 mg|
|Naproxen tablets||250 mg to 500 mg|
|Naproxen sodium tablets||550 mg to 1100 mg|
|Piroxicam tablets||40 mg|
|Tolfenamic acid tablets||200 mg to 400 mg|
|Diclofenac sodium IM||50 mg|
|Butorphanol nasal spray||1 mg to 2 mg|
Table 2: Specific Migraine Medications: Triptans
|Sumatriptan||Oral tabletNasal spraySubcutaneous injection||25 mg, 50 mg, 100 mg5 mg, 20 mg6mg||200 mg40 mg12 mg|
|Almotriptan||Tablet||12.5 mg||25 mg|
|Eletriptan||Tablet||20 mg, 40 mg||80 mg|
|Frovatriptan||Tablet||2.5 mg||7.5 mg|
|Naratriptan||Tablet||1 mg, 2.5 mg||5 mg|
|Rizatriptan||Oral tabletOrally disintegrating tablet||5 mg, 10 mg5 mg, 10 mg||30 mg30 mg|
|Sumatriptan / naproxen sodium||Tablet||85 mg/500 mg||170mg/1000 mg|
|Zolmitriptan||Oral tabletOrally disintegrating tablet||2.5 mg, 5mg2.5 mg, 5mg||10 mg10 mg|
Putting it All Together
Medications are a tool useful for managing attacks of migraine. A daily headache diary is a tracking system to measure the effectiveness of treatment and a foundation for a future management strategy.