Migraine medications fall into two broad categories: Medications designed to reduce the pain and other symptoms, and those designed to prevent headaches from happening in the first place.

Story by: David Steen Martin on September 15, 2021

Migraine medications fall into two broad categories: medications designed to reduce the pain and other symptoms, and those designed to prevent headaches from happening in the first place.

Migraine medications that reduce symptoms of a migraine attack are sometimes called rescue medications.

“The primary goal with rescue medications is to achieve relief of pain, associated symptoms and disability within two hours of use,” said Jeffrey H. Frank, M.D., headache specialist at Norton Neuroscience Institute.

Rescue medications should not be used more than twice a week because of the risk of medication overuse headaches.

“In treating migraine, we oftentimes suggest using higher doses of medications initially, and then backing down if there are side effects,” Dr. Frank said. “The goal here is to be pain-free with tolerable side effects rather than have pain and have no side effects.”

A number of medications not specifically for migraine attacks can work to reduce symptoms. These include:

• Gepants, a new class of treatment, block CGRP — a protein in the brain that has been identified as a migraine trigger. The treatments have a relatively low risk of serious side effects and a low risk of medication overuse. Rimegepant is approved for both acute treatment of migraine attacks and as a preventive medication. Ubrogepant is available to treat attacks. Another medication is in clinical trials for treatment of migraine attacks.

• Nonsteroidal anti-inflammatory drugs, such as ibuprofen and naproxen sodium, can be bought over the counter. Diclofenac (Cambia) and ketorolac (Toradol) are available by prescription.
• Acetaminophen usually doesn’t help severe migraine attacks, but can be used for mild headache.
• Excedrin, a combination of acetaminophen, aspirin and caffeine, is approved by the Food and Drug Administration (FDA) for mild migraine attacks.
• Eight medications specifically for migraine attacks belonging to a class of drugs called triptans: Amerge, Axert, Frova, Imitrex, Maxalt, Relpax, Zomig and Treximet.

“The earlier you take the triptans, the better they work,” Dr. Frank said.

Axert, Maxalt, Relpax and Zomig are quick-acting. Amerge and Frova are slow-acting, which means they stay in the system longer, and may be used in combination with other drugs such as naproxen or Cambia.

Preventive migraine medications are designed to reduce the number of migraine attacks.

“Who needs preventive medications? Patients who are using frequent rescue medications, maybe on the way to developing medication overuse headaches,” Dr. Frank said.

Preventive medications also can help people who have disabling migraine attacks that don’t respond to the rescue medications, or someone who simply wants to prevent the headaches from coming on rather than treat them symptomatically.

Antiseizure medications are the most frequently used preventive medications, with Topamax the most-prescribed among them.

“It’s effective in nearly 50% of the patients who take it,” Dr. Frank said of Topamax.

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Topamax can have significant side effects, including numbness and tingling in the hands and feet and sometimes around the mouth, and cognitive difficulties like not being able to find words. It can reduce sweating, meaning athletes who take it are at risk for overheating. It’s also been linked to birth defects and can also decrease the effectiveness of oral contraceptives.

An alternative for people who don’t tolerate Topamax is Zonegran. This is another antiseizure medication that can be used as a preventive migraine medication, though the side effects are similar. Other antiseizure medications that can be used as preventive medication include Depakote and Valproate, though their side effects include weight gain and hair loss.

Other preventive migraine medications include:

• Rimegepant is approved for both prevention and symptom treatment. Another preventive drug is in clinical trials.
• Antidepressants such as Elavil and Pamelor, which cause drowsiness and are taken at night. Vivactil is stimulating and taken three times a day. Others, including Prozac, Celexa, Effexor, Cymbalta and Pristiq, also can be used.
• Blood pressure medications including Propranolol, Metoprolol, Nadolol, Verapamil and Diltiazem.
• Vitamin supplements including magnesium and riboflavin, and herbs such as butterbur and feverfew.
• Botox injections, effective for chronic migraine, defined as more than 15 days of headache per month. Botox treatment involves injections at 31 sites every three months.

“Most patients who get it and have a good response don’t mind the 31 Botox injections. They feel it’s a small price to pay for three months of good headache control,” Dr. Frank said.

Monoclonal antibody injections are the latest FDA-approved migraine medications, with drugs such as Emgality and Ajovy.

“The goal of treatment is to decrease the frequency and severity of the headaches,” Dr. Frank said, “not to get rid of the headaches completely.”