Which Medications are Best to Treat Acute Migraine?

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May 31, 2022
May 17, 2021
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Which Medications are Best to Treat Acute Migraine?

Medications for Acute Migraine

Whenever we think about treating migraine, we typically break each kind of treatment down into one of two groups.  There are treatments that help when a migraine attacks, called “acute treatments”.  And there are treatments that are done whether the headache is there or not, called “preventive treatments”.  In this article we will focus on acute treatments.

There are many kinds of acute treatments.  When a migraine comes, we often recommend going into a dark, quiet room and avoiding anything that may have triggered the migraine.  Hydrating yourself can be very helpful, as can deep breathing exercises.   A number of medications can also effectively shorten the attack, and improve many of the other non-pain migraine symptoms as well.  In general, any time you are going to use a medication to stop a migraine in its tracks, you should treat it as early as possible - preferably within the first two hours. Migraines that linger are much more difficult to treat.

Over-the-Counter Medications

Most people start treatment with medications that they can find over-the-counter.  Tylenol, ibuprofen (Advil/Motrin), Aleve and Excedrin are all commonly used for many pain conditions, migraine included.  None of these treatments are specific for migraine, but if used sporadically may improve some of the pain.  If you use any of these medications more than two or three times weekly you may start to cause “rebound” headaches from medication overuse. This is in addition to other issues that can happen if you take some medications too often, like stomach pain, liver toxicity and kidney problems.

Butalbital

Two older medications (Fiorecet and Fiorenal) contain something called butalbital.  This is a derivative of phenobarbital - an addictive medication that is not recommended anymore for most indications.  Using butalbital, even once per week, is associated with those “rebound” headaches, and most headache specialists recommend other medications rather than Fiorecet and Fiorenal.

Triptans

Seven medications are in the triptan family.  These are migraine-specific, and target a serotonin receptor that is dysregulated during migraine. Each medicine in this family is a little different - some have longer half-lives, some are more or less potent.  There is a limitation to the frequency of triptan use as well: 2-3 times weekly (but most can be repeated in a day).  These can cause vasoconstriction - spasm of the blood vessels in the body - and if you are at high risk for heart attacks, stroke or blood clots, triptans are not recommended. 

Anti-Nausea Medications

Some anti-nausea medications can also be used to stop a migraine acutely.  Most of these are medications that block the neurotransmitter dopamine, as dopamine can become deregulated during a migraine attack.  The most effective emergency room IV medicine for migraine is actually an anti-nausea medication called Reglan.  Some of these medications can be sedating, but most are very well tolerated.  If you continue to experience nausea even after treating with another medication, you can take an anti-nausea medication as well. 

Gepants

A new class of acute migraine medications was first approved in 2020.  These medications (Nurtec and Ubrelvy, with two more to follow) are also migraine-specific but work differently than the triptans.  They block an inflammatory neurotransmitter called CGRP which is produced by the brain during a migraine attack.  They are not associated with vasoconstriction and at this time are considered safer options for people at higher vascular risk. 

DHE

Recently, there has been more good news for people with migraine. In early September 2021, the Food and Drug Administration (FDA) approved a new variation of medication - Trudhesa nasal spray for the acute treatment of migraine in adults. You may have received DHE before if you received intravenous treatment for a prolonged migraine attack at a hospital or at an infusion center.

The waiting time to get an appointment with a neurologist to get the correct treatment can take up to a few months. If you are looking to start an acute treatment for your migraine, try Neura Health and talk to the specialist about what might work best for you.

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Thomas Berk, MD
Thomas Berk is Medical Director at Neura Health and a former Clinical Assistant Professor at the Department of Neurology at NYU Grossman School of Medicine.
About the Author
Thomas Berk, MD is Medical Director of Neura Health and a neurologist and headache specialist based in New York City. A former Clinical Assistant Professor at the Department of Neurology at NYU Grossman School of Medicine, he has over 12 years of clinical experience. He graduated from the NYU Grossman School of Medicine and completed his neurology residency at NYU as well. He completed a headache fellowship at the Jefferson Headache Center in Philadelphia. He is an emerging leader of the American Headache Society and has been on the Super Doctors list of rising stars for the past five years.

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