Many different medications are used to treat migraines. Some migraines respond to non-prescription pain relievers such as ibuprofen, acetaminophen, naproxen, or aspirin. Among prescription drugs, triptans and ergotamine are the only types of medications approved by the U.S. Food and Drug Administration (FDA) for migraine treatment.
Other types of drugs, including opioids and barbiturates, are sometimes prescribed off-label for migraine treatment. Opioids and barbiturates have not been approved by the FDA for migraine relief, and they can be addictive.
All FDA-approved migraine treatments are approved only for adults. No migraine products have officially been approved for use in children.
Some patients with mild migraines respond well to over-the-counter (OTC) painkillers, particularly if they take a full dose of the medicine at the very first sign of an attack. OTC pain relievers, also called analgesics, include:
- Nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin, generic), naproxen (Aleve, generic), and aspirin. Products marketed as Advil Migraine or Motrin Migraine Pain are simply ibuprofen in a liquid-filled capsule.
- Acetaminophen (Tylenol, generic). Excedrin Migraine contains a combination of acetaminophen, aspirin, and caffeine.
There are also prescription-only NSAIDs such as diclofenac (Cataflam, generic).
NSAID Side Effects. High dosages and long-term use of NSAIDs can increase the risk for heart attack, stroke, kidney problems, and stomach bleeding. Aspirin does not increase the risk for heart problems, but it can cause other NSAID-related side effects. Frequent or daily use of NSAIDs may worsen migraines and lead to the development of medication overuse headache. The American Headache Society advises against using OTC medications for headache more than twice a week.
Triptans (also referred to as serotonin agonists) were the first drugs specifically developed for migraine treatment. They are the most important migraine drugs currently available. They help maintain serotonin levels in the brain. Serotonin is one of the major brain chemicals involved in migraines.
Triptans are recommended as first-line drugs for adult patients with moderate-to-severe migraines when NSAIDs are not effective. Triptans have the following benefits:
- They are effective for most patients with migraine, as well as patients with both tension-type and migraine headaches.
- They do not have the sedative effect of other migraine drugs.
- Withdrawal after overuse appears to be shorter and less severe than with other migraine medications
Sumatriptan. Sumatriptan (Imitrex, generic) has the longest track record and is the most studied of all triptans. Sumatriptan is effective for many patients, but for some people headache recurs within 24 hours after taking the drug.
Sumatriptan is available as a fast-dissolving pill, nasal spray, injection, orskin patch. Injected sumatriptan works the fastest of all the triptans and is the most effective, but it can cause pain at the injection site. The nasal spray form is absorbed more quickly than the oral form. Some patients report relief as soon as 15 minutes after administration. The spray tends to work less well when a person has nasal congestion from cold or allergy. It may also leave a bad taste.
The newest form of sumatriptan (Zecurity) is a single-use battery-powered skin patch that is applied to the upper arm or thigh when a migraine attack occurs. Pressing a button activates the patch to deliver the drug during a 4-hour period. The patch is approved to treat both migraine pain and nausea.
Other Triptans. Newer triptans include almotriptan (Axert), zolmitriptan (Zomig), naratriptan (Amerge, generic), rizatriptan (Maxalt), frovatriptan (Frova), and eletriptan (Relpax). Treximet combines in one pill both sumatriptan and the anti-inflammatory pain reliever naproxen (Aleve, generic). Frovatriptan is also recommended for prevention of menstrual migraine; naratriptan and zolmitriptan may also possibly be effective for menstrual migraine.
Although triptans, (like all migraine medications), are approved only for adults, researchers are investigating zolmitriptan for treating migraines in adolescents.
Side Effects. Side effects of triptans may include:
- Tingling and numbness in the toes
- Sensations of warmth
- Discomfort in the ear, nose, and throat
- Muscle weakness
- Heaviness or pain in the chest (especially with sumatriptan)
- Rapid heart rate
Complications of Triptans. The following are potentially serious problems.
- Complications of heart and circulation. Triptans narrow (constrict) blood vessels. Because of this effect, spasms in the blood vessels may occur and cause serious side effects, including stroke and heart attack. Such events are rare, but patients with an existing history or risk factors for these conditions should generally avoid triptans.
- Serotonin syndrome. Serotonin syndrome is a life-threatening condition that occurs from an excess of the brain chemical serotonin. Triptan drugs used to treat migraine, as well as certain types of antidepressant medications, can increase serotonin levels. These antidepressant drugs include serotonin reuptake inhibitors (SSRIs) -- such as fluoxetine (Prozac, generic), paroxetine (Paxil, generic), and sertraline (Zoloft, generic) -- and selective serotonin/norepinephrine reuptake inhibitors (SNRIs), such as duloxetine (Cymbalta) and venlafaxine (Effexor, generic). It is very important to not combine a triptan drug with a SSRI or SNRI drug. Serotonin syndrome is most likely to occur when starting or increasing the dose of a triptan or antidepressant drug. Symptoms include restlessness, hallucinations, rapid heartbeat, tremors, increased body temperature, diarrhea, nausea, and vomiting. You should seek immediate medical care if you have these symptoms.
The following people should avoid triptans or take them with caution and only under a doctor's supervision:
- Anyone with a history or any risk factors for stroke, uncontrolled diabetes, high blood pressure, or heart disease.
- People taking antidepressants that increase serotonin levels.
- Children and adolescents. They may be safe, but controlled studies are needed to confirm this. (Triptans should not, in any case, be the first-line treatment for children.)
- People with basilar or hemiplegic migraines. (Triptans are not indicated for these migraineurs.)
- Triptans do not appear to increase the risk for birth defects. Still, women should be cautious about taking any medications during pregnancy and discuss any possible adverse effects with their doctors.
Drugs containing ergotamine (commonly called ergots) constrict smooth muscles, including those in blood vessels, and are useful for migraine. They were the first anti-migraine drugs available. Ergotamine is available by prescription in the following preparations:
- Dihydroergotamine (DHE) is an ergot derivative. It is administered as a nasal spray form (Migranal) or by injection, which can be performed at home.
- Ergotamine is available as tablets taken by mouth, tablets taken under the tongue (sublingual), and rectal suppositories. Some of the tablet forms of ergotamine contain caffeine.
Ergotamine does not work as well as triptans but may still be helpful for patients with status migrainous or those with frequent recurring headaches.
Side Effects. Side effects of ergotamine include:
- Tingling sensations
- Muscle cramps
- Chest or abdominal pain
The following are potentially serious problems:
- Toxicity. Ergotamine is toxic at high levels.
- Adverse effects on blood vessels. Ergot can cause persistent blood vessel contractions, which may pose a danger for people with heart disease or risk factors for heart attack or stroke.
- Internal scarring (fibrosis). Scarring can occur in the areas around the lungs, heart, or kidneys. It is often reversible if the drug is stopped.
The following patients should avoid ergots:
- Pregnant women. Ergots can cause miscarriage.
- People over age 60.
- Patients with serious, chronic health problems, particularly those with heart and circulation conditions.
Ergotamine can interact with other medications, such as antifungal drugs and some antibiotics. All ergotamine products approved by the FDA contain a "black box" warning in the prescription label explaining these drug interactions. The FDA-approved ergotamine products are:
- Migergot suppository
- Ergotamine tartrate and caffeine tablets
- Cafergot tablets
- Ergomar sublingual tablets
If migraine pain is very severe and does not respond to other drugs, some doctors recommend painkillers containing opioids. Opioid drugs include morphine, codeine, meperidine (Demerol, generic), and oxycodone (Oxycontin)]. Butorphanol is an opioid in nasal spray form that may be useful as a rescue treatment when others fail.
Opioids are not approved for migraine treatment and should not be used as first-line therapy. Nevertheless, opioid products are prescribed to many patients with migraine, sometimes with dangerous results. For example, following reports of several drug-related deaths, the FDA warned that the cancer pain pill fentanyl (Fentora, generic) should not be used to treat patients with migraine or others conditions for which the drug is not specifically approved.
Side Effects. Side effects for all opioids include drowsiness, impaired judgment, nausea, and constipation. There is a risk for addiction, and these drugs can become ineffective with long-term use for chronic migraines. They may also increase the risk of making episodic migraines become chronic and heightening sensitivity to pain. Doctors should not prescribe opioids to patients at risk for drug abuse, including those with personality or psychiatric disorders.
Drugs Used for Nausea and Vomiting
Metoclopramide (Reglan, generic) is used in combination with other drugs to treat the nausea and vomiting that sometimes occur either as a medication side effect or migraine symptom. Metoclopramide and other anti-nausea drugs may help the intestine better absorb migraine medications. The battery-powered sumatriptan skin patch (Zecurity) is approved to treat both migraine nausea and pain.