Migraine Treatment

Authored by Dr Colin Tidy, 22 Oct 2014

Patient is a certified member of
The Information Standard

Reviewed by:
Prof Cathy Jackson, 22 Oct 2014

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. If you have frequent or severe attacks of migraine, another option is to take a medicine to prevent migraines. Below you will find information on migraine medicines to treat migraine. Find out more about medicines to prevent migraine.

There are four types of medicines that are commonly used to treat migraine attacks:

  • Ordinary painkillers
  • Anti-inflammatory painkillers
  • Anti-sickness medicines
  • Triptans.
  • Painkillers

Paracetamol and aspirin both work 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.

Strictly speaking, aspirin is an anti-inflammatory painkiller (see below). 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 (see under 'Further Reading and References', below) 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.

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 (including aspirin) probably work better than paracetamol to ease migraine. You can buy aspirin or ibuprofen at pharmacies or obtain them on prescription. 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.

Migraine attacks may cause a feeling of sickness (nausea) or cause you to actually be sick (vomit). The nausea makes it harder for your body to absorb migraine 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.

Some brands of migraine 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. Triptans are a group (class) of medicines that are used to ease the symptoms of a migraine attack or cluster headache. They include almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, and come in various different brand names. They are also known as 5-HT1 agonists. They come as migraine tablets (both to be swallowed and in dispersible form), as an injection and as nasal spray preparations. You need a prescription for most triptans, but you can buy sumatriptan from pharmacies.

How do triptans work?

Triptans are not painkillers. Triptans work by imitating the action of a brain chemical called 5-hydroxytryptamine (5-HT). 5-HT is also known as serotonin. 5-HT gives instruction to cells by attaching to specific sites (receptors) on the outside of them, rather like a password triggering a computer programme or a key opening a lock. One of the effects 5-HT has is to cause widened (dilated) blood vessels to narrow (constrict). For this reason, 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.) They may also reduce the release of other brain chemicals that occurs during a migraine attack.

How do you take a triptan?

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 and do not take it to prevent one from coming on. Studies have shown that they do not work as well if taken too early. Triptans taken by mouth are designed to work rapidly - within an hour or so. Injected triptans usually work in 10-15 minutes.

After you have taken the first dose:

  • If the triptan worked to relieve your headache but then the headache returned later, you can repeat the dose after 2-4 hours. Each triptan has a maximum daily dose that you should not exceed. This will be written on the packet.
  • If the triptan did not work at all, a second dose is unlikely to work, so do not take a second dose. The exception to this is zolmitriptan (2.5 mg), where a second dose may be tried after two hours even if the first dose did not work. See the patient leaflet that comes in the medicine packet for details.

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 after just using a particular triptan once. The British Association for the Study of Headache (BASH) recommends that you try each triptan for three separate migraine attacks before deciding to change to a different one. 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. If the triptan you try doesn't work for you, your doctor may also advise a change in the way in which the medicine is given in some cases. For example, if feeling sick (nausea) or being sick (vomiting) usually occurs during your migraine attack, migraine medication that you don't have to swallow is likely to be more effective for you (see below).

What are the side-effects of triptans?

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. Triptan sensations in the chest can mimic heart pains (angina) and may cause alarm. Whilst these sensations are not usually harmful, if you develop intense chest pain or sensations, you should consult a doctor immediately or go directly to the nearest accident and emergency department (you may need to dial 999/112/911 for an ambulance).
  • 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 as a 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 as tablets (orally) or 40 mg as a nasal spray (intranasally). Also, note: if you take frequent doses of a triptan there is a danger that you may get 'rebound' headaches called 'medication-induced headache' (see below).
  • 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.

Can I buy triptans or are they just on prescription?

Sumatriptan can be bought, without a prescription, from pharmacies, although only after an assessment by the pharmacist. Triptans should only be taken to treat migraine or cluster headache that has been previously diagnosed by your doctor, as there are other causes of headache besides migraine and cluster headache, and you need a diagnosis. The other triptans apart from sumatriptan are only available on prescription.

Who cannot take triptans?

A full list of people who should not take triptans is included with the patient leaflet that comes in the medicine packet. If you are prescribed a triptan, read this to be sure you are safe to take it. In particular, you should not take a triptan:

  • If you have uncontrolled high blood pressure (hypertension).
  • If you have, or are told you are at high risk of developing, cardiovascular disease (such as angina, or heart attack).
  • If you have had a stroke or transient ischaemic attack (TIA).
  • If you have coronary vasospasm such as Prinzmetal's angina (this is rare).
  • If you are pregnant.
  • When breast-feeding, unless you have taken the following into account:
    • Traces of triptans are passed out in breast milk, so they should either be avoided during breast-feeding, or milk should be expressed and discarded for 12-24 hours after taking them (see manufacturer's information).
  • Without advice from your doctor if you have certain kidney or liver conditions. A reduced dose is recommended for some triptans if you are affected by one or more of such conditions.

Triptans should not be taken at the same time as migraine treatments containing ergotamine, as the combination of the two could be harmful. (Ergotamine is a migraine medication that is rarely used now.) If you stop taking a triptan you must wait before taking anything containing ergotamine. If you are taking ergotamine you must also wait before taking a triptan. This waiting period varies between 12 and 24 hours, depending on the type of triptan. Speak to your doctor or pharmacist if this applies to you.

There are age restrictions on the use of triptans:

  • Children younger than 12 years of age should not usually take triptans. (Triptans are not licensed for children younger than 12 but may occasionally be prescribed by a specialist paediatrician).
  • Adolescents (aged 12-18 years) may be prescribed sumatriptan nasal spray (10 mg).
  • Triptans are not licensed for people aged over 65 years.

What about risks?

Triptans are usually safe if you do not have any of the medical conditions mentioned above. Because these medicines can cause the constriction of blood vessels, they should not be given to people with heart or blood vessel problems.

If you take triptans too often, you increase your risk of developing medication-induced headache:

Medication-induced headache (also called medication overuse headache or analgesic headache) is caused by taking painkillers or triptans too often for headaches of any kind. 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. For example:

  • You may have a bad spell of tension headaches or migraine attacks, perhaps during a time of stress. You take painkillers or a triptan more often than usual, and for a while. Your body becomes used to the medication. A withdrawal (rebound) headache then develops if you do not take a painkiller or triptan within a day or so of the last dose. You think this is another tension headache or migraine attack, and so you take a further dose of painkiller or triptan. When the effect of each dose wears off, a further withdrawal headache develops, and so on. In time, you may have headaches on most days, or on every day, and you end up taking painkillers or a triptan every day, or on most days.

If you find that you are getting headaches on most days then this may be a cause. See a doctor for advice. Some people who may think they are getting frequent migraine attacks or are developing chronic migraine, are in fact getting medication-induced headache.

If you use painkillers or a triptan on more than two days per week on a regular basis, you are at risk of developing medication-induced headache.

See separate leaflet called Medication-induced (Medication-overuse) Headache.

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.

Treatment of each menstrual migraine attack is the same as for any other type of migraine. However, there are treatments that may prevent menstrual migraines from occurring.

Many of the medicines used by adults for migraine are not licensed for children. Paracetamol or ibuprofen is suitable and commonly used. Apart from these you must check with your doctor or pharmacist before giving a child any other medicine for migraine.

  • Paracetamol or ibuprofen is suitable. Do not use aspirin.
  • As regards anti-sickness medicines, domperidone is licensed for children of all ages, and prochlorperazine is licensed for children older than 12 years.
  • Triptans are not licensed for children and so should not be used (see above).

Many of the medicines used to treat migraine should not be taken by pregnant or breast-feeding women.

  • For relief of a migraine headache:
    • Paracetamol is the medicine most commonly used, as it is known to be safe during pregnancy.
    • Ibuprofen is sometimes used but do not take it in the last third of the pregnancy (the third trimester).
    • Aspirin - avoid if you are trying to conceive, early in pregnancy, in the third trimester and whilst breast-feeding.
    • Triptans - should not be taken by pregnant women at all. Triptans can be used during breast-feeding, but milk should be expressed and discarded for 12-24 hours after the dose (see manufacturer's information on the packet).
  • For feeling sick (nausea) and being sick (vomiting) - no medicines are licensed in pregnancy. However, occasionally a doctor will prescribe one 'off licence'.
  • Medicines used for the prevention of migraine are not recommended for pregnant or breast-feeding women.

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.

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 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 Trigger Diary. It includes a migraine diary that you may like to print out and use.

Many people take medicines to prevent a migraine attack from happening in the first place. Find out more about medicines to prevent migraine.

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 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.

Further reading and references

Can Botox cure your migraines?
Migraine Trigger Diary

I have had pain and pressure in my eyes and temples for almost a year now. My face feels fuzzy and tingly and I feel woozy a lot of the time. Nothing takes the pain away when it is really bad. Tried...

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