Introduction

The goal of acute migraine treatment is consistent, fast and complete relief of symptoms with reduced disability and without headache recurrence. This makes it important to match the treatment to the level of disability to gain the best possible relief and prompt return to function.  To achieve this your doctor will first establish the diagnosis of migraine, the level of disability and the presence of other conditions that will affect the choice of treatment.

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.

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.

Non-steroidal anti-inflammatory drugs (NSAIDs)

There is good evidence for aspirin, ibuprofen, naproxen, diclofenac, ketorolac. Caution is advised in people with a history or risk of bleeding, those with renal problems and asthma.  Prolonged regular use (more than 15 days/month) of any NSAID is associated with increased risk of mediation overuse headache. During migraine attacks, gut absorption slows and medication absorption may be improved when taken with an anti-sickness treatment like domperidone. Early treatment during the pain phase is recommended.

Combinations

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.

Paracetamol is generally not effective for migraine attacks but may be combined in some treatments to improve benefit 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 (MOH) risks being high.

Other painkillers

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

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.

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.

Triptans are acute migraine-specific medicines. They come as tablets and some as nasal sprays, dissolvable melts or an injection. Injectable formulations will bypass gut absorption and provide the fastest relief. This may be convenient in the presence of nausea and vomiting or if attacks develop quickly to severe and disabling.

However, triptans will not be suitable or effective for everyone.  People with coronary heart disease, cerebrovascular disease, peripheral vascular disease, uncontrolled hypertension, risk for acute vascular conditions and the potential for drug interactions with using these drugs, will not be able to use them safely.

Some side effects associated with triptan use 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. While these and other side effects are not uncommon, the triptans are a very safe class of medications when used appropriately by the people for whom they are prescribed. If side effects are intolerable, or if their effects trouble you, you should always refer to your doctor for review with the possibility to try a few options to find the one most suitable for you or determine if you should continue using them.

Frequent use (more than 10 days/month regularly) is associated with medication overuse headache (MOH).

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.

Future Treatments: Ditans and Gepants

Ditans and Gepants are new migraine treatments that are specifically designed to target the migraine process. They are expected in the near future and come with fewer side effects.
Ditans and gepants are medicines that can be taken acutely. They come as a tablet to be taken at the start of an attack to treat pain and associated migraine symptoms (e.g. pain, nausea, light/noise sensitivity). They do not appear to cause medication overuse headache.

The gepants (ubrogepant, rimegepant)

Gepants work to block CGRP from attaching to its receptor on the nerves involved in initiating pain signals. Compared to a triptan, the proportion of people who will be pain free in 2 hours is smaller, but with the lack of an effect on other systems (for example they do not constrict blood vessels), their side effect rate is much less. They will be beneficial to the significant group of people who cannot take a triptan for those reasons.

Ditans (lasmiditan)

Ditans are also migraine-specific and do not affect blood vessels. These affect a specific serotonin receptor, only found on nerves and not blood vessels. This makes them suitable for people who cannot take a triptan for this reason. Taken at the first sign that a migraine is starting, it has the potential to stop the development of the headache and enable the return to normal function. Possible side effects are dizziness and tiredness in about 15% of people.

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.

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