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.
  • 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.
  • 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.

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)

Generic name Formulation type Prescription required
Aspirin Tablets, dispersible tablets, suppositories, enteric coated tablets. No
Ibuprofen Tablets, modified release tablets, suspension, granules. No
Diclofenac Tablets Yes
Naproxen Tablets, enteric coated tablets. Yes
Tolfenamic acid Clotam® rapid tablets. Yes
Flurbiprofen Tablets Yes

Other painkillers

Generic name Formulation type Prescription required
Paracetamol Tablets, soluble tablets, capsules, suppositories, suspension, oral solution, sachet containing powder. No
Codeine phosphate Tablets, injection, syrup.  Combinations also available as dispersible tablets, tablets, capsules, sachets. Depends on formulation (may be OTC when combined with aspirin or paracetamol)

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)

Brand name Formulation type Prescription required
Generic Tablets Yes
Motilium® Tablets Yes

Metoclopramide

Brand name Formulation type Prescription required
Generic Tablets, solution, injection. Yes
Maxolon® Tablets, injection. Yes
Paramax®: Metoclopramide combined with paracetamol Tablets, sachets containing effervescent powder. Yes
MigraMax®: Metoclopramide combined with aspirin Sachets containing powder. Yes

Prochlorperazine

Brand name Formulation type Prescription required
Generic Tablets, buccal tablets (dissolve in the mouth). Yes
Buccastem® Buccal tablets (dissolve in the mouth). Yes
Stemetil® Tablets, syrup, injection. Yes

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)

Brand name Formulation type Prescription required
Generic Tablets, injection. Yes
Imigran® Tablets, dispersible tablets, nasal spray, injection. Yes
Boots Migraine Relief® Tablets P (see key)
Imigran Recovery® Tablets P
Migraitan® Tablets P

Almotriptan

Brand name Formulation type Prescription required
Generic Tablets Yes
Almogran® Tablets Yes

Eletriptan

Brand name Formulation type Prescription required
Replax® Tablets Yes

Frovatriptan

Brand name Formulation type Prescription required
Migard® Tablets Yes

Naratriptan

Brand name Formulation type Prescription required
Generic Tablets Yes
Naramig® Tablets Yes

Rizatriptan

Brand name Formulation type Prescription required
Generic Tablets, dispersible tablets (dissolve on tongue) Yes
Maxalt Melt® Wafer (dissolve on tongue) Yes
Maxalt® Tablet Yes

Zolmitriptan

Brand name Formulation type Prescription required
Generic Tablets, dispersible tablets (dissolve on tongue) Yes
Zomig® Tablets, nasal spray Yes
Zomig Rapimelt® Dispersible tablets Yes

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.

Generic name Brand name Formulation type Prescription required
Ergotamine tartrate Migril®: Ergotamine, cyclizine and caffeine Tablets Yes

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.

Brand name Formulation type Prescription required
Midrid®: Isometheptene with paracetamol Capsules Yes, but also P (see key above) – packs of 15 and under may be sold under the supervision of a pharmacist.