Which migraine medication is best

Triptans should be avoided in patients with vascular disease, uncontrolled hypertension, or hemiplegic migraine. Intravenous antiemetics, with or without intravenous dihydroergotamine, are effective therapies in an emergency department setting.

Dexamethasone may be a useful adjunct to standard therapy in preventing short-term headache recurrence. Intranasal lidocaine may also have a role in relief of acute migraine. Isometheptene-containing compounds and intranasal dihydroergotamine are also reasonable therapeutic options. Medications containing opiates or barbiturates should be avoided for acute migraine. During pregnancy, migraine may be treated with acetaminophen or nonsteroidal anti-inflammatory drugs prior to third trimester , or opiates in refractory cases.

Acetaminophen, ibuprofen, intranasal sumatriptan, and intranasal zolmitriptan seem to be effective in children and adolescents, although data in these age groups are limited. Migraine headache is one of the most common, yet potentially debilitating disorders encountered in primary care. Approximately 18 percent of women and 6 percent of men in the United States have migraine headaches, and 51 percent of these persons report reduced work or school productivity.

Enlarge Print. Abortive therapy should be used as early as possible in the course of a migraine. Combination analgesics containing aspirin, caffeine, and acetaminophen are an effective first-line abortive treatment for migraine.

Parenteral dexamethasone is useful as an adjunctive treatment in the emergency department to help prevent short-term headache recurrence. Opiates and barbiturate-containing compounds should not be routinely used for abortive treatment of migraine. Table 1 lists International Headache Society diagnostic criteria for migraine with and without aura.

In a primary care setting, the probability of migraine is 92 percent in patients who report at least four of the five POUND symptoms. Headache has at least two of the following: Aggravation by or causing avoidance of routine physical activity e. Recurrent disorder manifesting in headaches of reversible focal neurologic symptoms that usually develop gradually over five to 20 minutes and last for less than 60 minutes. Headache with the features of migraine without aura usually follows the aura symptoms.

Aura consisting of at least one of the following, but no motor weakness: Fully reversible dysphasic speech disturbance. At least one aura symptom develops gradually over five minutes or different aura symptoms occur in succession over five minutes. Headache fulfilling criteria for migraine without aura begins during the aura or follows aura within 60 minutes. Information from reference 2. Table 2 outlines other serious causes of headache that must be considered in the differential diagnosis of migraine, such as temporal arteritis, cluster headache, and acute glaucoma.

The U. Headache Consortium recommends considering neuroimaging in patients with an unexplained abnormal finding on neurologic examination and in patients with atypical headache features or headaches that do not fulfill the strict definition of migraine or other primary headache disorder.

In one study, age older than 50 years, sudden onset, and abnormal neurologic examination predicted serious intracranial pathology in adults presenting to an emergency department with nontraumatic headache; the presence of any one of these three features detected serious intracranial pathology with Associated with blurred vision, nausea, vomiting, and seeing halos around lights; ophthalmologic emergency.

Antecedent trauma; may have subacute onset; altered level of consciousness or neurologic deficit may be present. Often abrupt onset; associated with nausea, vomiting, dizziness, blurred vision, and papilledema; may have cranial nerve V1 palsy; aggravated by coughing, straining, or changing position. May be insidious or associated with dyspnea; occurs more commonly in colder months.

Cause of stroke; can be spontaneous or follow minor trauma or sudden neck movement; unilateral headache or face pain; ipsilateral Horner syndrome. Worse with neck movement; posterior distribution; pain is neuralgic in character and sometimes referred to vertex or forehead; more common in older patients.

Uncommon; sudden onset; duration of minutes to hours; repeats over a course of weeks, then may disappear for months or years; unilateral lacrimation and nasal congestion; severe unilateral and periorbital pain; more common in men; patient is restless during episode.

Neurologic abnormalities, confusion, altered mental status or level of consciousness. Usually worse when lying down; nasal congestion; tenderness over affected sinus.

Occipital location; tenderness at base of skull; pain is neuralgic in character and referred to vertex or forehead. Worse on awakening; generally progressive; aggravated by coughing, straining, or changing position. Chronic headache with few features of migraine; tends to occur daily; hormone therapy and hormonal contraceptives are frequent culprits; includes analgesic rebound.

Antecedent head trauma; vertigo, lightheadedness; poor concentration and memory; lack of energy; irritability and anxiety. Almost exclusively in patients older than 50 years; associated with tenderness of scalp or temporal artery and jaw claudication; visual changes. Pain generally involves the temporomandibular joint and temporal areas; associated with symptoms when chewing.

Common; duration of 30 minutes to seven hours; typically bilateral; nonpulsating; mild to moderate intensity without limiting activity; no nausea or vomiting. Adapted with permission from Wilson JF. In the clinic. Migraine [published correction appears in Ann Intern Med.

Ann Intern Med. Several medications from different classes are available to treat acute migraine Table 3 7 — Because relatively few trials have directly compared the different medication classes available to treat acute migraine, definitive treatment algorithms cannot be developed. More than one-half of persons treat their migraine headaches with nonprescription medications, and patients often present to physicians after unsuccessfully trying multiple nonprescription therapies.

Headache Consortium guidelines offer a general strategy based on expert consensus. Triptans are considered first-line abortive treatment of moderate to severe migraine, or mild attacks that have not responded to nonprescription medicines. Ergotamine-containing compounds may also be reasonable in this situation. Heartburn, gastric bleeding, ulcers, rebound headache, renal toxicity; can exacerbate heart failure and hypertension.

Available without a prescription; many patients have already tried nonprescription NSAIDs before seeking medical advice. Almotriptan Axert. Should be avoided in patients with a history of myocardial infarction, cerebrovascular accident, Prinzmetal angina, uncontrolled hypertension, or other vascular diseases, and in pregnant women.

Eletriptan Relpax. Frovatriptan Frova. Naratriptan Amerge. Rizatriptan Maxalt. Sumatriptan Imitrex. Intranasal : 5 to 20 mg, can be repeated in 2 hours, not to exceed 40 mg per day. Oral : 25 to mg, can be repeated in 2 hours, not to exceed mg per day.

Subcutaneous : 4 to 6 mg, may repeat in 1 hour, not to exceed 12 mg per day. Intranasal : 5 mg, may repeat in 2 hours, not to exceed 10 mg per day. Oral disintegrating tablets : 2. Oral : 1. Metoclopramide Reglan. Dexamethasone [ corrected ]. Hyperglycemia, mood changes, insomnia; multiple adverse effects with long-term use.

Intranasal : 1 spray in each nostril, repeat once after 15 minutes; not to exceed 4 sprays per attack, 6 sprays per day, 8 sprays per week. IV dosing can be used in combination with 10 mg metoclopramide every 8 hours as needed for nausea. Subcutaneous : 1 mg every hour; not to exceed 3 mg per day. Cautions When taking over-the-counter painkillers, always make sure you read the instructions on the packaging and follow the dosage recommendations.

They may prescribe stronger painkillers or recommend using painkillers along with triptans. Triptans If ordinary painkillers are not helping to relieve your migraine symptoms, you should make an appointment to see a GP. Triptans are available as tablets, injections and nasal sprays. Common side effects of triptans include: warm sensations tightness tingling flushing feelings of heaviness in the face, limbs or chest Some people also experience feeling sick, a dry mouth and drowsiness.

These side effects are usually mild and improve on their own. As with other painkillers, taking too many triptans can lead to a medication overuse headache. This is so you can discuss their effectiveness and whether you had any side effects. If the medicine was helpful, treatment will usually be continued. Anti-sickness medicines Anti-sickness medicines, known as anti-emetics, can successfully treat migraine in some people even if you do not experience feeling or being sick.

These are prescribed by a GP, and can be taken alongside painkillers and triptans. They usually come in the form of a tablet, but are also available as a suppository. Combination medicines You can buy a number of combination medicines for migraine without a prescription at your local pharmacy. These medicines contain both painkillers and anti-sickness medicines. If you're not sure which one is best for you, ask your pharmacist.

It can also be very effective to combine a triptan with another painkiller, such as ibuprofen. Many people find combination medicines convenient.

Acupuncture If medicines are unsuitable or do not help to prevent migraines, you can try acupuncture. Some GP surgeries offer acupuncture, but most do not, so you may have to pay for it privately. Agency for Healthcare Research and Quality. Diagnosis and treatment of headache. Updated January Accessed November 8, Guideline for primary care management of headache in adults. Can Fam Physician. Becker WJ. Acute migraine treatment.

Continuum Minneap Minn. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society [published correction appears in Neurology. Derry S, Moore RA. Paracetamol acetaminophen with or without an antiemetic for acute migraine headaches in adults.

Cochrane Database Syst Rev. Aspirin with or without an antiemetic for acute migraine headaches in adults. Ibuprofen with or without an antiemetic for acute migraine headaches in adults. Meta-analysis of the efficacy and safety of naproxen sodium in the acute treatment of migraine. Acetaminophen, aspirin, and caffeine in combination versus ibuprofen for acute migraine: results from a multicenter, double-blind, randomized, parallel-group, single-dose, placebo-controlled study.

Acetaminophen, aspirin, and caffeine versus sumatriptan succinate in the early treatment of migraine: results from the ASSET trial. Triptans in the acute treatment of migraine: a systematic review and network meta-analysis. Sumatriptan all routes of administration for acute migraine attacks in adults - overview of Cochrane reviews.

Sumatriptan-naproxen for acute treatment of migraine: a randomized trial. Syed YY. Sumatriptan plus naproxen for the treatment of acute migraine attacks in adults. Comparative tolerability of treatments for acute migraine: a network meta-analysis.

Saper JR, Silberstein S. Pharmacology of dihydroergotamine and evidence for efficacy and safety in migraine. Rescue therapy for acute migraine, part 2: neuroleptics, antihistamines, and others [published correction appears in Headache. Prochlorperazine vs. J Emerg Med. Rescue therapy for acute migraine, part 3: opioids, NSAIDs, steroids, and post-discharge medications.

Intravenous magnesium sulphate in the acute treatment of migraine without aura and migraine with aura. A randomized, double-blind, placebo-controlled study.

A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs. Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine. A randomized open-label study of sodium valproate vs sumatriptan and metoclopramide for prolonged migraine headache.

Am J Emerg Med. Intravenous sodium valproate versus prochlorperazine for the emergency department treatment of acute migraine headaches: a prospective, randomized, double-blind trial. Ann Emerg Med. Diphenhydramine as adjuvant therapy for acute migraine: an emergency department-based randomized clinical trial.

Migraine therapeutics in adolescents: a systematic analysis and historic perspectives of triptan trials in adolescents.

JAMA Pediatr. Drugs for the acute treatment of migraine in children and adolescents. Acute treatment therapies for pediatric migraine: a qualitative systematic review. Treatment of pediatric migraine in the emergency room. Pediatr Neurol. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society.

Triptan exposure during pregnancy and the risk of major congenital malformations and adverse pregnancy outcomes: results from the Norwegian Mother and Child Cohort Study [published correction appears in Headache.

Management of the acute migraine headache. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.

This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv aafp. Want to use this article elsewhere? Get Permissions. Read the Issue. Sign Up Now. Feb 15, Issue. Acute Migraine Headache: Treatment Strategies. Author disclosure: No relevant financial affiliations. A 8 , 11 , 12 , 15 — 19 Triptans are a first-line treatment for moderate to severe migraine.

A 8 , 22 , 23 The choice of triptan should be individualized based on the patient's migraine characteristics and on the route of administration, pharmacokinetics, and cost. C 8 , 22 , 23 Dopamine antagonist antiemetics are second-line treatments for migraine. American Academy of Neurology Do not prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders.

American Headache Society Do not recommend prolonged or frequent use of over-the-counter pain medications for headache. International Headache Society Diagnostic Criteria for Migraine Headache With and Without Aura Migraine without aura Headache lasts 4 to 72 hours untreated or unsuccessfully treated Headache has at least 2 of the following: Aggravation by or causing avoidance of routine physical activity e.

TABLE 1. TABLE 2. TABLE 3. TABLE 4. TABLE 5. TABLE 6. TABLE 7. Read the full article. Anticonvulsants prevent seizures caused by epilepsy and other conditions. They may also alleviate migraine symptoms by calming overactive nerves in your brain. The FDA has approved Botox Botulinum toxin type A injections in your forehead or neck muscles for the treatment of chronic migraine. Many drugs are available to treat pain from migraines.

Be cautious of the overuse of medication to avoid rebound headaches. Read this article in Spanish. Migraine symptoms might keep you in bed. Try these natural remedies that might help get you back on your feet faster.

Toradol is one drug used for migraine pain. No matter how long it lasts, migraines or severe migraines can be exhausting and debilitating.

Find out what triggers or causes are responsible for an…. Learn about herbal remedies for migraines. Gabapentin is an anticonvulsant used off-label to help prevent migraine attacks.

For some migraine patients, overusing certain pain medications can actually make headaches worse. Learn what to look for and what to ask your doctor.

If you have migraines, clinical trials may help you find a treatment that works. Learn more about participating in a clinical trial. Neurontin and Lyrica are both drugs for migraine prevention.