Treatment Options for Migraine Headache

Goals of Treatment of Migraine Headache

The primary goal of treatment for migraine headache is the immediate relief of the acute headache, also called abortive treatment. It is crucial that abortive treatment begin as early as possible after the headache begins since the longer one waits, the more difficult it is for treatment to be effective. Treatment for acute headache includes:

  • Nonpharmacologic or supportive strategies
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Migraine-specific medications
  • Rescue medications

Nonpharmacologic Supportive Strategies

When a person feels a migraine headache beginning, there are various steps they can take to minimize or reduce the intensity of the headache, including:

  • Remove yourself from any stressful situation
  • Lie down in a cool, dark, quiet place
  • Place a cool wet cloth on the forehead
  • Take medication for nausea if needed, such as prochlorperazine (Compazine) which comes as an oral or suppository formulation; or metoclopramide (Reglan) which comes in tablet form

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) such as aspirin, acetaminophen (e.g., Tylenol), ibuprofen (e.g., Advil) or naproxen (e.g., Aleve) are analgesic drugs (pain relievers) that are typically the first-line medications for moderate migraine headaches but not for severe headaches. Most NSAIDs are available over-the-counter (OTC) without a prescription. They can be taken individually or in combination and are typically taken at higher doses than for an average, non-migraine headache.

Side effects of NSAIDs when taken at high doses for an extended period of time include:

  • Abdominal pain
  • Bleeding
  • Ulcers
  • Rebound headaches, if taken more than 2-3 times a week or in very large doses. The medication itself becomes the cause of rebound headaches.

The U.S. Food and Drug Administration has approved the following three OTC medications for migraine headache:

  • Excedrin Migraine
  • Advil Migraine
  • Motrin Migraine

Prescription NSAIDs may also be helpful, however, they may cause adverse abdominal side effects at the high doses necessary for efficacy of aborting a migraine headache.

Migraine-Specific Medications

Migraine-specific drugs block the underlying mechanism of migraine headache. They are considered serotonin receptor agonists which means that they bind to the receptors in the brain cells that regulate the release of serotonin. Reduced levels of serotonin result in dilation of the blood vessels which causes the headache pain. Triptans effectively break the cycle of the migraine.

Abortive migraine-specific medications include:

  • Triptans
  • Ergotamines and ergot derivatives
Triptans

Several triptans have been approved by the US Food and Drug Administration (FDA) for treatment of acute migraine headache, including:

  • Sumatriptan (Imitrex) -available as a nasal spray, rapidly dissolvable pill, or self-injectable formulation
  • Rizatriptan (Maxalt) - available as a rapidly dissolvable pill that can be taken without water
  • Zolmitriptan (Zomig) - available as a nasal spray
  • Eletriptan (Relpax)

Triptans are especially effective for severe headaches that cause significant disability. They relieve pain, nausea, light and sound sensitivity. Certain triptans, such as sumatriptan and zolmitriptan, are efficacious within two hours and have response rates of up to 70%. If a patient responds poorly to one triptan, others should be tried. Migraineurs who suffer from nausea can benefit from the alternate forms of medication delivery (such as nasal spray or injectable formulation).

Triptans should not be used in the presence of:

  • Ischemic cardiac disease
  • Cerebrovascular disease
  • Occlusive vascular disease
  • Uncontrolled hypertension

The dose of triptans can be raised if needed and NSAIDs may be added on for increased effect. For patients who are difficult to treat, different strategies may need to be tried until the most effective treatment is identified. If a headache recurs after a migraine was successfully treated, triptan drugs can be repeated if the recommended time between doses has elapsed. The patient may also want to try to change the delivery mode with the second dose (e.g., nasal, or injectable) to see if the relief is greater. Triptans are more effective and more tolerable than ergots (see below), though they are more expensive.

Triptans present a moderate risk for rebound headaches due to over-use. The Mayo Clinic suggests that they not be taken more than nine times a month. Side effects of triptans include:

  • Nausea
  • Dizziness
  • Muscle weakness
Ergot Alkaloids

Ergot drugs have been used for treatment of migraine headaches since the 1920's. They are not as effective as triptans and have more severe side effects. Ergot drugs include:

  • Ergotamine (Caffergot) - combination of ergot and caffeine
  • Ercaf - suppository of ergotamine and caffeine
  • Dihydroergotamine (Migranal, DHE 45) - an ergot derivative that is available as a nasal spray or self-injectable formulation. Migranal and DHE 45 are more effective, less expensive, and have fewer side effects than ergotamine. They enter the bloodstream more quickly than pills and may be a good choice for people with very rapid onset of migraine headache.

Ergotamine was commonly used for migraine before the development of triptans.

Rescue Medications

If a migraineur is not helped by the above medications within four hours, or cannot tolerate them, there may be a need for a "rescue drug" which consists of some form of fast-acting narcotic or opioid, including:

  • Butalbital combination - barbiturate sedative combined with aspirin, acetaminophen, caffeine, or codeine. It carries a high risk of rebound headaches and is not used often. This is often used as a "rescue drug".
  • Butorphanol (Stadol) - this is formulated as a nasal spray and is not typically associated with addiction or dependency.