Medicines which are used to treat migraine attacks (episodes) include painkillers, anti-inflammatory painkillers, anti-sickness medicines, and triptans. Most people with migraine can find a treatment that works reasonably well for most attacks. However, children, and pregnant and breast-feeding women have a limited choice as many anti-migraine and anti-sickness medicines are not suitable for them.
This leaflet is part of our series on migraine
What is migraine?
Migraine is a condition that causes attacks (episodes) of headaches, and often other symptoms such as being sick (vomiting). Between migraine attacks, the symptoms go completely. See separate leaflet called Migraine which gives general details about migraine.
This leaflet is about medicines which can be used to treat each attack of migraine. (If you have frequent or severe attacks of migraine, another option is to take a medicine to prevent migraines. See separate leaflet called Medicines to Prevent Migraine Attacks for more details.)
There are four types of medicines that are commonly used to treat migraine attacks:
- Ordinary painkillers
- Anti-inflammatory painkillers
- Anti-sickness medicines
These are discussed below.
Paracetamol works well for many migraine attacks. Take a dose as early as possible after symptoms begin. If you take painkillers early enough, they often reduce the severity of the headache, or stop it completely. A lot of people do not take a painkiller until a headache becomes really bad. This is often too late for the painkiller to work well.
Take the full dose of painkiller. For an adult this means 900 mg aspirin (usually three 300 mg tablets) or 1,000 mg of paracetamol (usually two 500 mg tablets). Repeat the dose in four hours if necessary. Soluble tablets are probably best, as they are absorbed more quickly than solid tablets.
It is best not to use codeine and medicines containing codeine, such as co-codamol, to treat migraine. This is because codeine can make feeling sick (nausea) and being sick (vomiting) worse, which can make migraine worse. They are also more likely than paracetamol or aspirin to cause a condition called medication-induced headache if you use them frequently (see below).
Anti-inflammatory painkillers probably work better than paracetamol to ease migraine, for example ibuprofen, which you can buy at pharmacies or obtain on prescription and aspirin. Strictly speaking, aspirin is an anti-inflammatory painkiller. Other types such as diclofenac, naproxen, or tolfenamic acid need a prescription. Also, some points about anti-inflammatories include:
- It may be best to take the maximum allowed dose as soon as the headache begins rather than taking smaller doses.
- Ideally, take an anti-inflammatory medicine with some food or milk. This helps to reduce the risk of developing a stomach upset which some people have with these medicines. However, this may not be possible if you feel sick (nausea) or are sick (vomit).
- One brand of ibuprofen dissolves and disperses in the mouth, and is swallowed with saliva. This may be easier to take than other tablets if you feel sick.
- One brand of diclofenac comes as a suppository. This may be useful if you usually vomit with a migraine attack.
- Some people with asthma, high blood pressure, kidney failure, or heart failure may not be able to take anti-inflammatory painkillers.
- For a full list of cautions and possible side-effects for your particular medicine, see the leaflet that comes in the medicine packet.
Note: recently, aspirin has fallen from favour for the treatment of many painful conditions. However, for migraine, it often works very well and is worth a try. A review of research studies published in 2010 (cited at the end of this leaflet) confirms the place of aspirin. The review concluded that aspirin (at full dose) either takes away migraine pain, or greatly reduces the pain, within two hours in more than half of the people who take it.
Dealing with nausea and vomiting
Migraine attacks may cause a feeling of sickness (nausea) or cause you to be sick (vomit). The nausea causes poor absorption of tablets into your body. If you take painkillers, they may remain in your stomach and not work well if you feel sick. You may even vomit the tablets back. Tips that may help include:
- Use soluble (dissolvable) painkillers. These are absorbed more quickly from your stomach and are likely to work better.
- As mentioned, one brand of diclofenac comes as a suppository. This may be useful if you usually vomit with a migraine.
- You can take an anti-sickness medicine in addition to painkillers. A doctor may prescribe one - for example, domperidone, prochlorperazine or metoclopramide.
- Like painkillers, anti-sickness medicines work best if you take them as soon as possible after symptoms begin.
- An anti-sickness medicine, domperidone, is available as a suppository if you feel very sick or vomit during migraine attacks.
- Prochlorperazine comes in a buccal form which dissolves between the gum and cheek. This can be useful if you feel sick and do not wish to swallow a tablet.
Combinations of medicines
Some brands of tablets contain both a painkiller and an anti-sickness medicine - for example, Paramax®, and MigraMax®. They may be convenient. However, the dose of each part (constituent) may not suit everyone, or be strong enough. You may prefer to take painkillers and anti-sickness medicines separately so that you can control the dose of each, and you know exactly what you are taking.
A triptan is an alternative if painkillers or anti-inflammatory painkillers do not help much. Triptan medicines include almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan. They each have different brand names too. You need a prescription for most triptans, but you can buy sumatriptan from pharmacies.
Triptans are not painkillers. They work by interfering with a brain chemical called 5HT. An alteration in this chemical is thought to be involved in causing migraine.
Do not take a triptan too early in an attack of migraine. (This is unlike painkillers described above which should be taken as early as possible.) You should take the first dose when the headache (pain) is just beginning to develop, but not before this stage. That is, do not take it in the aura stage if you have an aura. Studies have shown that they do not work as well if taken too early.
If the first dose of the triptan does not work, do not take a further dose, as it is not likely to work either. The exception to this is zolmitriptan, where a second dose can be tried even if the first does not work.
If a low dose does not work so well, your doctor may prescribe a larger dose. Also, some triptans work in some people and not in others. Therefore, if one triptan does not work, the same one at a higher dose, or a different one, may well do so. In some cases, some people have tried three or more different triptans before finding one that works best for them. However, do not make a judgement until you have tried a particular triptan for 2-3 migraine attacks. Even in people where triptans work well, a triptan does not work for every migraine attack. The aim is to find the one that works most of the time for you. See your doctor to discuss trying a higher dose, or a different one, if the first one does not seem to help much.
Read the leaflet in the packet for possible side-effects. If side-effects occur they are usually mild and do not usually last long. The most common include:
- A warm-hot sensation, tightness, tingling, flushing, and feelings of heaviness or pressure in areas such as the face, arms, legs and occasionally the chest.
- Some people feeling a little unsteady or dizzy, developing a dry mouth, or feeling sick (nausea).
- Drowsiness which can be caused by sumatriptan. If this occurs, do not do skilled tasks such as driving.
The way side-effects affect different people can vary between the different triptans. So, if one causes unpleasant side-effects, a switch to a different one may be fine.
A migraine attack itself can often cause nausea and being sick (vomiting). This can cause problems in taking triptan tablets. Options to consider if this is a problem include:
- Sumatriptan, which is also available as an injection.
- Rizatriptan and zolmitriptan, which are available as a wafer or tablet that disperses in the mouth, and is then swallowed with saliva.
- Zolmitriptan and sumatriptan, which are available as a nasal spray.
- Also, taking an anti-sickness medicine such as domperidone or metoclopramide (see above).
Most people who have migraine can usually find a triptan that works well for most migraine attacks, and where side-effects do not occur or are not too bad. A main problem with triptans is that in about one in four cases, after taking a triptan which clears a headache, the headache returns within the next 48 hours. If this problem tends to happen with you, then options to consider are:
- You can take a repeat dose when the headache returns (if the first dose worked). A dose of triptan can be repeated within 2-4 hours (depending on the type). But, make sure you do not exceed the maximum dose recommended over a 24-hour period. For example, total dosage of sumatriptan per 24 hours should not exceed 300 mg orally (tablets) or 40 mg intranasally (nasal spray). Also, note: if you take frequent doses of a triptan there is a danger that you may get 'rebound' headaches called 'medication headache'.
- Your doctor may consider prescribing naratriptan or eletriptan. Return of the headache is thought to be less common after treatment with these triptans.
- Some people take a short course of an anti-inflammatory painkiller such as diclofenac or tolfenamic acid in the 24-48 hours after the headache goes. This may prevent a return of the headache and reduce the need for a repeat dose of a triptan.
Some people cannot take triptans. For example, some people with heart disease, stroke disease, or peripheral arterial disease. Also, people at an increased risk of developing these conditions. Your doctor will advise. Also, pregnant women and children should not take triptans.
More on combination treatments
If none of the above treatments is useful, there is some evidence to suggest that the combination of sumatriptan (a triptan) plus naproxen (an anti-inflammatory painkiller) works better than either medicine alone. However, it is best to talk it through with your doctor before embarking on these sorts of combinations.
A note of caution - medication-induced headache
Medication-induced headache is caused by taking painkillers or triptans too often for tension-type headaches or migraine attacks (episodes). It is a common cause of headaches that occur daily, or on most days. About 1 in 50 people develop this problem at some time in their lives. If you find that you are getting headaches on most days then this may be a cause. See a doctor for advice. See separate leaflet called Medication-induced Headache for more details.
Medicines for migraine attacks in children
Many of the medicines used by adults for migraine are not licensed for children. Paracetamol or ibuprofen are suitable and are commonly used. Apart from these you must check with your doctor or pharmacist before giving a child any other medicine for migraine. For example, triptans are not licensed for children and only some anti-sickness medicines can be used.
Medicines for migraine attacks when pregnant or breast-feeding
The good news is that about two in three women with migraine have an improvement whilst pregnant or breast-feeding. However, about 1 in 20 women with migraine find that their migraine gets worse whilst pregnant.
The bad news is that most of the medicines used to treat migraine (and sickness) should not be taken if you are pregnant or breast-feeding. Paracetamol is the medicine most commonly used, as it is known to be safe during pregnancy. If you are pregnant or breast-feeding you should always check the leaflet that comes with the medicine to see if it is suitable. Check with your pharmacist or doctor if you are not sure.
From the above information you can see that there are several options to try when you have a migraine attack (episode). Many people under-treat their migraine attacks or do not realise that if one treatment does not work then it is normal to try a different treatment for the next migraine attack. You can discuss the options with your doctor.
In short, it is normal and common to try different treatment options for migraine over a period of time. The purpose is to be certain that you have found what treatment or treatment combination suits you best.
As a general rule, it is best to use the same treatment for three migraine attacks to assess how well it works. This is because, even if one treatment normally works for you, there will be times when it may not work so well. You may even wish to keep a diary for a while. For example, write down an account of each migraine attack, symptoms and severity. Also, record exactly what treatment you used for that attack, and the dose. And, when the attack is over, make a note as to how well the treatment had worked, and how quickly, and whether you had any side-effects. In this way you will be able to be objective and find which is the best treatment for you. See separate leaflet called Migraine - Triggers and Diary which includes a migraine diary that you may like to print out and use.
How to use the Yellow Card Scheme
If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at the following web address: www.mhra.gov.uk/yellowcard.
The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:
- The side-effect.
- The name of the medicine which you think caused it.
- The person who had the side-effect.
- Your contact details as the reporter of the side-effect.
It is helpful if you have your medication - and/or the leaflet that came with it - with you while you fill out the report.
Dr Tim Kenny
Dr Colin Tidy
Dr John Cox