Acute medicines

Taken when an attack occurs to treat the symptoms

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.

Caution

Drugs and new treatments for migraine are changing all the time.  If you are on long term medication you should ensure that your treatment is regularly reviewed by your doctor. 

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
  • OTC – over the counter medication
  • ® – registered
  • Enteric coated – tablets can be coated with a substance that enables them to pass through the stomach and into the intestine unchanged.
  • IV – 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.

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.

 
 Group Name Generic Name Prescription required Brand Name Formulation type 
Non-steroidal anti-inflammatory drugs (NSAIDs) Asprin No 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 antiemetic.

Combinations specifically licensed for migraine include:

  • Migraleve® – OTC

Pink tablets – codeine, paracetamol  & buclizine

Yellow tablets – codeine & paracetamol

  • Paramax® – POM

Paracetamol & metoclopramide

Tablets, dispersible tablets, suppositories, enteric coated tablets.
Ibuprofen No Tablets, modified release tablets, suspension, granules.
Diclofenac Yes Tablets, modified release tablets, dispersible tablets, injection, suppositories.
Naproxen Yes Tablets, enteric coated tablets.
Tolfenamic acid Yes Clotam® rapid tablets.
Flurbiprofen Yes Tablets, modified release tablets, suppositories.
Other Paracetamol No Tablets, soluble tablets, capsules, suppositories, suspension.
Codeine phosphate Depends on formulation (may be OTC when combined with aspirin or paracetamol) Tablets, injection, syrup.  Combinations also available as dispersible tablets, tablets, capsules, sachets.

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.

Group Name Generic Name Prescription required Brand Name  Formulation type
Phenothiazines Domperidone Some preparations are OTC Generic form Tablets
Motilium® OTC Tablets, suppositories, suspension.
Metoclopramide Yes Generic form Tablets, solution, injection.
Maxolon® Tablets, syrup, injection.
Maxolon SR® Capsules
Paramax® – Metoclopramide combined with paracetamol Tablets, sachets containing effervescent powder.
MigraMax® – Metoclopramide combined with aspirin Sachets containing powder.
Prochlorperazine Yes Generic form Tablets
Buccastem® Buccal tablets (dissolve in the mouth).
Stemetil® Tablets, syrup, effervescent granules, injection, suppositories.

Specific anti-migraine drugs

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

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.

Group Name Generic Name Prescription required Brand Name Formulation type
Serotonin (5-HT1) agonists or
‘Triptans’
Sumatriptan Yes, tablets available on prescription and OTC after assessment by pharmacist. Imigran® Tablets, injection, nasal spray.
Almotriptan Yes Almogran® Tablets
Eletriptan Yes Relpax® Tablets
Frovatriptan Yes Migard® Tablets
Naratriptan Yes Naramig® Tablets
Rizatriptan Yes Maxalt®, Maxalt Melt® Tablets, wafers.
Zolmitriptan Yes Zomig®, Zomig Rapimelt® Tablets, nasal spray, wafers.

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 4 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.

Group Name Generic Name Prescription required Brand Name Formulation type
Ergot Alkaloids Ergotamine tartrate Yes Cafergot® – Ergotamine and caffeine Tablets
Migril® – Ergotamine, cyclizine and caffeine Tablets (Medihaler® discontinued)

Other – Isometheptene mucate:

Action – 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.

Group Name Generic Name Prescription required Brand Name Formulation type
Other Isometheptene mucate Yes, but also available OTC – packs of 15 and under may be sold under the supervision of the pharmacist. Midrid® – Isometheptene with paracetamol Capsules