If you open up a utility box and peer inside, you’ll see an array of different tools, each designed for a specific purpose. It’s the same with medicines that help migraine. Different situations require different types of medicines. Some medicines are meant for prevention, to keep an attack from happening in the first place. Other medicines give you relief once the migraine attack has arrived. Still others are medicines of last resort during a migraine attack, when you need serious help breaking the migraine cycle.
Your doctor is your go-to expert to answer individual questions, but here’s an overview of the basics.
Before an Attack: Preventive Medications
Migraine prevention meds are prescription medications taken regularly (anywhere from daily to monthly to every three months) to help prevent migraine attacks. Their goal is to decrease your number of days with migraine attacks and/or the severity of the attacks when they do occur. Another benefit: Fewer attacks means you’ll need fewer doses of pain relief meds, overuse of which takes its own toll.
If you have any of these situations, it may be time to explore preventative medication. Consider preventives if:
- You have at least one migraine attack per week
- Your medicines for stopping a migraine attack aren’t giving you enough relief or create intolerable side effects
- If you’re taking more pain relief medicine than directed
- You experience debilitating symptoms, such as long-lasting aura, despite taking appropriate migraine-stopping meds
Starting on preventive medicines requires patience and commitment. With an oral medication, a doctor will start their patient on a low dose and slowly increase the dosage. With that gradual approach, it may take up to eight weeks for the medication to begin working. Other medications, such as Botox injections, take as long as six months.
Many prevention medications for migraine may sound familiar because they were developed for other purposes — for example, to prevent seizure, high blood pressure, depression, or wrinkles. But research has shown they also provide significant benefit for people with migraine.
Examples of Preventive Migraine Medications
- Beta-blockers: propranolol (Inderal), metoprolol (Toprol), timolol (Blocadren), nadolol (Corgard), atenolol (Tenormin)
- Nonselective tricyclic antidepressants (TCAs): amitriptyline (Elavil), nortripyline (Pamelor), protriptyline (Vivactil)
- Selective serotonin and norepinephrine reuptake inhibitors (SNRIs): venlafaxine (Effexor), duloxetine (Cymbalta)
- CGRP monoclonal antibodies: (Aimovig, Ajovy, Emgality, and VYEPTI)
- Neuromodulating drugs: antiepileptic drugs, including divalproex sodium (Depakote), gabapentin (Neurontin), topiramate (Topamax, Trokendi)
- Neurotoxin: botulinum toxin (Botox)
You and your doctor should consider your medical history and other medications you take to determine which migraine prevention medication is best for you.
During an Attack: Acute Migraine Medications
Acute medicines are those you take as needed to stop or decrease a migraine attack once it has started. It includes over-the-counter and prescription drugs. Acute meds work best if you take them as soon as the migraine attack begins. Some come in nasal spray and injectable forms that work faster than pills, which is useful if your attacks come on with little warning and ramp up very quickly. They’re also worth considering if during attacks you can’t keep pills down due to severe nausea or vomiting.
Acute medications are very effective. If taken too frequently, however, they create a physical dependence called “rebound headache syndrome,” which actually increases headaches. Limit taking any acute medicine to less than ten days a month. Any more than that, and you may consider adding a preventive medicine to your management strategy.
Examples of Acute Migraine Medications
- Over-the-counter meds: NSAIDs (aspirin, ibuprofen, naproxen); acetaminophen; combination meds (e.g. Excedrin)
- Prescription Medications: prescription-strength NSAIDs; triptans (sumatriptan and other meds ending in –triptan); neuroleptics (prochlorperazine, metoclopramide); dihydroergotamine (aka DHE)
- New classes of prescription meds that have recently gotten FDA approval: gepants (ubrogepant, rimegepant), ditans (lasmiditan)
When All Else Fails: Rescue Medications for Migraine
Rescue medications are the final options to stop or decrease the agony of a severe attack that isn’t responding to less powerful meds. These are tablets, injections or suppositories that are used only when absolutely necessary, under a doctor’s supervision, because they are often sedating, and can have significant side effects. A doctor may administer them for three to seven days to break the headache cycle. Your doctor might also recommend you visit an outpatient infusion center or the emergency room for intravenous medication.
Examples of Rescue Medications for Migraine
- NSAIDs: Toradol (tablet or injection)
- Corticosteroids: prednisone (tablet), dexamethasone (tablet or injection)
- Neuroleptics: Prochlorperazine (Compazine) or Chlorpromazine (Thorazine)
- Intravenous infusions: typically a combination of several medications including DHE, ketorolac, neuroleptics, valproic acid, and/or steroids
Now that you know the three different ways you can use medicines to help migraine — for symptom prevention, during an attack, and a last-ditch rescue — take a moment to think about how any of them could positively affect your life with headache and migraine. Having the right tools in your migraine toolbox gives you the confidence of knowing you’re prepared! Consult your doctor for the best plan for you.