Introduction

Over the years there have been positive developments in acute medication for migraine. These treatments can’t stop you from getting migraine but they can reduce your pain and other symptoms.

Drugs called triptans have been designed especially for migraine attacks. Their main effect is to reduce pain information coming to the brain.

Recommended acute treatments – simple analgesics and antiemetics

Recommended acute treatments – triptans

(Tables taken from the British Association for the Study of Headache’s National Headache Management System for Adults 2019)

Caution

For a small percentage of people with headache, frequent use of drugs particularly ergotamine, triptans, codeine, paracetamol, NSAIDs and caffeine have been implicated in chronic daily headache and medication-overuse headache.  If you are experiencing four or more migraine attacks per month you should consider the use of preventive treatment to avoid attacks.

Key

• POM – Prescription only medication.
• P – Sold by a qualified pharmacist.
• OTC – over the counter medication.
• ® – registered trademark.
• Enteric coated – tablets can be coated with a substance that enables them to pass through the stomach and into the intestine unchanged.
• IM – intramuscular injection
• BNF – British National Formulary is the joint publication published by the British Medical Association and the Royal Pharmaceutical Society which is distributed to NHS doctors by the Department of Health.

For more information about a specific medicine, the electronic Medicines Compendium (eMC) website contains up to date, easily accessible information about medicines licensed for use in the UK.

Analgesics (painkillers)

Action

Analgesic drugs relieve pain and reduce stiffness associated with migraine.  The non-steroidal anti-inflammatory drugs (NSAIDs) also reduce inflammation by inhibiting the production of certain chemicals in the body.

Analgesics tend to be more effective when taken as soluble, effervescent or liquid formulations because they are absorbed quicker (not all drugs are available in these forms).

Enteric coated preparations are less suitable for treating migraine attacks because they are absorbed more slowly and therefore may take longer to work.

Codeine is an analgesic which blocks pain signals in the spinal cord and brain.

Caffeine is a weak stimulant that is often combined in small amounts with analgesics to enhance their effect.  However, there is evidence that caffeine can provoke headache and may result in headaches following its withdrawal after long term treatment.

Brand names

There are many different preparations of analgesics so the brand names are too numerous to mention.

Several combination preparations are available.  The most commonly used contain aspirin or paracetamol combined with codeine, caffeine and/or an anti-emetic. Combinations specifically licensed for migraine include:

• Migraleve® – P or POM
  • Pink tablets: codeine, paracetamol and buclizin
  • Yellow tablets: codeine and paracetamol
• MigraMax® – POM: Aspirin and metroclopramide
• Paramax® – POM: Paracetamol and metoclopramide

Non-steroidal anti-inflammatory drugs (NSAIDs)

Other painkillers

Anti-emetics (anti-sickness)

Action

Anti-emetics relieve the nausea associated with migraine attacks.

Metoclopramide and domperidone also promote normal activity of the gut and can accelerate the absorption of analgesics.

Anti-emetics should be taken before or at the same time as analgesics.

Metoclopramide is associated with serious side effects (resulting in symptoms very like Parkinson’s disease) and should be avoided in children and young adults.

Phenothiazines (group name):

Domperidone (generic name)

Metoclopramide

Prochlorperazine

Specific anti-migraine drugs

Serotonin (5-HT₁) agonists or ‘Triptans’ (group name):

Action

Selective 5-HT₁ agonists relieve pain by narrowing blood vessels in the head and blocking the transmission of pain in sensory nerves supplying the skin and structures of the face.

Sumatriptan has been available for the longest period of time and is often compared to the newer triptans in trials.  If one triptan doesn’t work for you then it is worth trying a different one.

Sumatriptan (generic name)

Almotriptan

Eletriptan

Frovatriptan

Naratriptan

Rizatriptan

Zolmitriptan

Ergot Alkaloids:

Action

The BNF (British National Formulary – see the key above for explanation) states: “The value of ergotamine for migraine is limited by difficulties in absorption and by its side effects particularly nausea, vomiting, abdominal pain and muscle cramps.  It is best avoided.”

Recommended doses of ergotamine preparations should NOT be exceeded and treatment should not be repeated at intervals of less than four days.  To avoid tolerance, the frequency should be limited to no more than twice a month.  Patients should be warned to stop treatment if numbness or tingling of the extremities develops.  It is most effective if taken at the onset of a migraine attack.

Other – Isometheptene mucate:

Action

Isometheptene mucate (generic name) acts by constricting blood vessels in the head and the rest of the body. The BNF (British National Formulary) state that as more effective preparations are now available it is not widely used.

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