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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.