Acute medicines
Taken when a migraine attack occurs to treat the symptoms
What they are used for
Acute medicines for migraine are taken to stop or shorten the symptoms of a migraine attack. They are taken once an attack starts, not beforehand, and should have a quick effect on the migraine attack.
There are a range of different acute medicines that can be taken. They have different strengths and you should match the severity of symptoms of a migraine attack with the strength of the medicine. This should be discussed with your doctor.
Types of acute migraine medicine
The acute medicines that are recommended to treat migraine fall into three categories. Here is an overview of each category, and tables of the different types of drugs in these categories and how they are taken can be downloaded here (tables from current page).
Simple analgesics
This is medication that treats the pain of a migraine attack at the time they are taken and includes paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. It is medication that does not have opioids such a codeine in it. Painkillers that contain opioids are best avoided in migraine as benefits may be short-lived and they can be addictive.
Anti-emetics
This is medication that treats sickness (nausea and vomiting) that some people get with migraine attacks. They are also known as ‘anti-sickness’ medication.
During migraine attacks, gut absorption slows and medication absorption may be improved when taken with an anti-sickness medicine. Two anti-emetics, metoclopramide and domperidone, also help your body absorb the analgesics. Metoclopramide is associated with side effects (resulting in symptoms very like Parkinson’s disease, which is reversible) and should be avoided in children and young adults.
Anti-emetics should be taken before or at the same time as any analgesics you are taking for the migraine attack.
Triptans
This is medication that was designed to treat migraine attacks. They reduce the pain and sickness of a migraine attack at the time they are taken.
Triptans are very safe when used appropriately by the people for whom they are prescribed. You should take them at the start of the head pain. If a triptan works, but the pain comes back you can usually take a second dose within 24 hours. As with all medication triptans can have side effects. Common side effects include nausea; jaw, neck or chest tightness, pressure or squeezing; rapid heart rate; fatigue; numbness or tingling (especially involving the face); or a burning sensation over the skin. If side effects are intolerable, or if their effects trouble you, you should always contact your doctor for review.
When selecting a triptan, it is useful to consider how long your migraine attacks last and how quickly they develop. Some triptans such as naratriptan and frovatriptan usually take longer to reach their maximum effect but their effect lasts longer, and they often have fewer side effects. On the other hand, if your attacks peak quite quickly, a triptan such as sumatriptan, zolmitriptan, eletriptan or rizatriptan may be more appropriate.
Two doses of any triptan are allowed in 24 hours (maintaining a minimum 2-hour gap between doses). Triptans should not be used on more than 10 days per month. A nasal spray formulation (eg zolmitriptan, sumatriptan) works quicker than a tablet and an injection is even quicker and these may be appropriate if vomiting is prominent and treatment is needed quickly.
Some people experience side effects, and this will determine which triptan is the best choice. It is recommended that you try different triptans, treating at least 2 attacks with each, to find the one that works best for you. It is often a balance between side effects and benefit that determines the best choice.
If the side effects are too much, or the triptan you’ve been prescribed doesn’t work you should ask your doctor to try a different one. Other triptans may be more effective and have fewer side effects. It’s usually suggested you try a triptan for three separate attacks before deciding whether it’s suitable. You could also try different formulations such as a nasal spray or a tablet that dissolves on the tongue.
People with coronary heart disease, cerebrovascular disease, peripheral vascular disease, uncontrolled hypertension, and acute vascular conditions should not take them.
Gepants
These are calcitonin gene-related peptide (CGRP) receptor antagonists. Compared to conventional acute treatments such as triptans, non-steroidal anti-inflammatory drugs (NSAIDs), and other painkillers, the gepants don’t seem to cause rebound or medication overuse headache. As such, they may be useful as a preventive treatment when taken regularly.
It is a new treatment and currently being reviewed for use on the NHS.
You can read more about them here.
Taking different acute migraine medicines together
It is possible to combine a triptan with a NSAID especially for people with longer lasting attacks or those in whom migraine attacks tend to recur.
Several combination medicines are available. The most commonly used contain aspirin or paracetamol combined with codeine, caffeine and/or an antiemetic. Paracetamol is generally not effective for migraine attacks but may be combined in some treatments to improve the effectiveness e.g. Migraleve, Migramax. However, it is best to avoid codeine and opiates in migraine treatment as their benefits can be short term, with dependency and medication overuse headache risks being high.
Taking acute migraine medicines
Frequent use of drugs particularly ergotamine, triptans, codeine, paracetamol, NSAIDs and caffeine can lead to in chronic daily headache and medication-overuse headache in patients with migraine.
If you are experiencing four or more migraine attacks per month you should consider the use of preventive treatment to avoid attacks. Use of acute treatment on more than eight days a month has been reported to result in worsening of migraine and a reduction of the effect of any preventive treatment until the frequent use is addressed. Thus, although the use of a preventive medication taken daily for your migraine disorder seems unnecessary for four days a month, with acute treatment alone, the frequency may worsen and your migraine may become less responsive to treatment.
