- What are migraine headaches?
- What treatments are used for migraine relief?
- What types of medications are used for migraines?
- What are the possible side effects of migraine medications?
What are migraine headaches?
Migraine headaches are considered a neurological disorder that is common and usually more intense than most other headaches. They often are recurrent and have associated symptoms such as nausea, vomiting, and sensitivity to light.
What treatments are used for migraine relief?
Nondrug treatments or home remedies include:
- ice to the head,
- adequate sleep,
- smoking cessation, and
- avoidance of your food and environmental triggers (for example, stress, flashing lights, and drinking red wine).
Others recommend natural treatments such as
- group therapy, and
- many others.
Do nondrug treatments and home remedies work for migraines?
While nondrug methods may work for some, many doctors find these methods work poorly for many migraine patients. Consequently, drugs are used in the majority of patients with migraine headaches. In addition, patients do not respond to medications the same way. Unfortunately, sometimes doctors must try several different drugs to find what best works for you.
What types of medications are used for migraines?
The first drugs are analgesics like acetaminophen and NSAIDS. At best, they may help mild migraines. More severe migraines may respond to various triptans like sumatriptan (but not in pregnancy). Ergots like ergotamine or a combined drug like Midrin (isometheptene, acetaminophen and dichloralphenazone) may also be effective in stopping a migraine.
Although not recommended as initial treatment, some clinicians use narcotics and butalbital-containing drugs when triptans or other drugs fail. Since nausea and vomiting often accompany migraines, antinausea drugs like metoclopramide are often used with triptans. Some clinicians add an antidepressant to the treatment plan for some patients.
CGRP (calcitonin gene-related peptide) is a protein that causes meningeal inflammation and recently shown to cause migraine pain in most patients. Four companies decided to create antibodies against CGRP itself or its receptor on the meninges. The first of these new oral treatments, atogepant (Qulipta), was approved Sept. 28, 2021. It is a monoclonal antibody that is metabolized and becomes a CGRP-like receptor (receptor antagonist) that blocks CGRP from activating migraines. Another receptor antagonist approved by the FDA is erenumab-aooe (Aimovig), applied with an injector or prefilled syringe. Other monoclonal antibodies that are being developed are designed to interfere with the CGRP protein itself but have not yet been approved by the FDA. Although none of these treatments stop all migraines, the number of attacks and their intensity may be reduced significantly. The information below is still in effect, but this new monoclonal antibody approach to migraine headache treatment may cause changes in future guidelines.
AHS/AAN Migraine Prevention Guidelines: Drugs Recommended for Use
The medical experts (American Headache Society or AHS and American Academy of Neurology or AAN) that treat people with migraine headaches offered in 2012 extensive recommendations (guidelines) for medical treatments to prevent migraines. They are as follows:
Level A: Established as effective
Should be offered to patients requiring migraine prophylaxis
- Divalproex/sodium valproate: 400 to 1000 mg/day
- Metoprolol: 47.5 to 200 mg/day
- Petasites (butterbur): 50 to 75 mg twice daily
- Propranolol: 120 to 240 mg/day
- Timolol: 10 to 15 mg twice daily
- Topiramate: 25 to 200 mg/day
Level B: Probably effective
Should be considered for patients requiring migraine prophylaxis
- Amitriptyline: 25 to 150 mg/day
- Fenoprofen: 200 to 600 mg three times daily
- Feverfew: 50 to 300 mg bid; 2.08 to 18.75 mg three times daily for MIG-99 preparation
- Histamine: 1 to 10 ng subcutaneously twice a week
- Ibuprofen: 200 mg twice daily
- Ketoprofen: 50 mg three times daily
- Magnesium: 600 mg trimagnesium dicitrate/day
- Naproxen/naproxen sodium: 500 to 1100 mg/day for naproxen or 550 mg twice daily for naproxen sodium
- Riboflavin: 400 mg/day
- Venlafaxine: 150 mg extended release/day
- Atenolol: 100 mg/day
Level C: Possibly effective
May be considered for patients requiring migraine prophylaxis
- Candesartan: 16 mg/day
- Carbamazepine: 600 mg/day
- Clonidine: 0.75 to 0.15 mg/day; patch formulations also studied
- Guanfacine: 0.5 to 1 mg/day
- Lisinopril: 10 to 20 mg/day
- Nebivolol: 5 mg/day
- Pindolol: 10 mg/day
- Flurbiprofen: 200 mg/day
- Mefenamic acid: 500 mg three times daily
- Coenzyme Q-10: 100 mg three times daily
- Cyproheptadine: 4 mg/day
New drugs recommended for use to prevent migraines
These drugs are not yet categorized. More study is needed to determine how effective they are compared to other medications.
- Calcitonin-gene related peptide (CGRP) antagonists
- Monoclonal antibodies
- Eptinezumab (Vyepti): 100 mg as an intravenous infusion over approximately 30 minutes every 3 months; some patients may benefit from a dosage of 300 mg
- Erenumab (Aimovig): 70 mg as a subcutaneous injection once monthly; some patients may benefit from a dosage of 140 mg once monthly
- Fremanezumab (Ajovy): 225 mg as a subcutaneous injection monthly, or 675 mg every 3 months (quarterly)
- Galcanezumab (Emgality): 240 mg loading dose (administered as two consecutive injections of 120 mg each), followed by monthly doses of 120 mg
- Oral gepants (an older class of CGRP antagonist)
- Rimegepant (Nurtec): 75 mg taken orally, as needed for acute treatment of migraine as needed; 75 mg taken orally every other day for preventive treatment of episodic migraine
- Ubrogepant (Ubrelvy): 50 mg or 100 mg taken orally, as needed
- Monoclonal antibodies
What are the possible side effects of migraine medications?
There are many problems associated with the medical treatment of migraines. The major problems are that the drugs used to treat have side effects and have potentially dangerous interactions when used with other medications.
- Some (narcotics and butalbital) can be addictive.
- Special care of children and pregnant females with migraines is possible but usually a specialist (pediatric neurologist, neurologist, or OB/GYN) should be consulted before any treatment.
You and your doctor should carefully discuss the treatment methods to find the most effective treatment/prevention method that works for you.
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Loder, Elizabeth, et al. "The 2012 AHS/AAN guidelines for prevention of episodic migraine: a summary and comparison with other recent clinical practice guidelines." Headache 52.6 (2012): 930-945.
Taylor, Frederick R. "Acute treatment of migraine headaches." Seminars in Neurology 30.2 (2010): 145-153.