Migraine treatments and medications can be confusing. What to take when and which to take first can be hard to get used to, especially when we’re in the midst of a Migraine attack.
Let’s review the three purposes of Migraine medications and what types of medications are used for these purposes:
Preventive medications are intended to reduce the frequency and severity of Migraine attacks, and they’re generally taken daily. The exception to this is when Migraine attacks are triggered by sexual activity. In these cases, doctors sometimes prescribe a medication to take before sexual activity. This may be the only preventive a Migraineur uses, or it may be an additional medication to use only at these times.
There are over 100 medications and supplements currently being used for Migraine prevention. None of them was developed for Migraine prevention. All were originally developed for other conditions, then found to be helpful for Migraine prevention. The vast majority of medications used for Migraine prevention are prescribed off-label, which means that they have not been approved specifically for the treatment of Migraine. This is a common and completely legal practice. There are only four medications currently approved by the FDA for Migraine prevention:
- divalproex sodium (brand names Depakote, Depakote ER), a neuronal stabilizing agent, aka anticonvulsant, originally developed for seizure disorders
- propranolol (brand names Inderal, Inderal LA), which is a beta blocker originally developed for heart disease and hypertension
- timolol (brand name Blocadren), which is another beta blocker
- topiramate (brand name Topamax), which is another neuronal stabilizing agent
Medications prescribed off-label for Migraine prevention include:
- antihistamines such as cyproheptadine (Periactin)
- antihypertensive medications – blood pressure medications:
- ACE inhibitors such as benazepril (Lotensin) and fosinopril (Monopril)
- alpha-2 antagonists such as clonidine (Catapres)
- beta blockers such as metoprolol (Lopressor) and nadolol (Corgard)
- calcium channel blockers such as verapamil (Verelan) and diltiazem (Cardizem)
- MAOI antidepressants such as phenelzine (Nardil)
- SNRI antidepressants such as venlafaxine (Effexor)
- SSRI antidepressants such as escitalopram (Lexapro)
- Tricyclic antidepressants such as amitriptyline (Elavil)
- Cox-2 enzyme inhibitors such as celecoxib (Celebrex)
- muscle relaxants such as carisoprodol (Soma) and tizanidine (Zanaflex)
- neuronal stabilizing agents (anticonvulsants) such as levetiracetam (Keppra) and zonisamide (Zonegran)
- leukotriene blockers such as montelukast (Singulair) and zafirlukast (Accolate)
- medications generally used for ADD such as dextroamphetamine (Adderall) and atomoxetine (Strattera)
- medications developed for dementia or Alzheimer’s disease such as memantine (Namenda)
- dietary supplements such as Coenzyme Q10, vitamin B2 and magnesium
Abortive medications are generally the first-line acute medications to be taken when we get a Migraine unless, for some reason, we can’t take them. Unlike pain medications, which can only mask the pain for a few hours, abortive medications work to stop the Migrainous process itself, which stops the associated symptoms as well. Abortive medications work best when they’re taken early in a Migraine attack. Migraine abortive medications include:
- The triptans: Imitrex (also available as generic sumatriptan), Amerge (also available as generic naratriptan), Maxalt (also available as generic rizatriptan), Zomig (also available as generic zolmitriptan), Axert, Relpax, and Frova.
- Triptan / NSAID combination: Sumatriptan plus naproxen sodium.
- Ergotamines such as Migranal nasal spray and DHE-45 (injectable)
- Midrin equivalent medications: Isometheptene compounds such as Midrin. These medications contain Isometheptene Mucate, 65 mg; Dichloralphenazone, 100 mg; and Acetaminophen, 325 mg – a combination abbreviated as Isometh/Dich/Apap. Midrin and all but one Midrin equivalent medications have been pulled from the market. It’s uncertain if any will remain, but an equivalent medication can be made by a compounding pharmacy.
Triptans are sometimes used for preventing Migraines triggered by the hormonal fluctuations of the menstrual cycle. Amerge and Frova have been studied and proven effective for the prevention of menstrually triggered Migraines when taken twice a day for five to seven days beginning two days before the onset of the menstrual period.
Rescue medications are intended for use if and when abortives fail or if you can’t take the abortive medications. Most rescue medications are pain medications. Other types of medications are also used to help get through a Migraine by reducing nausea and helping Migraineurs relax. Rescue medications don’t have the ability to abort a Migraine, but will hopefully mask the pain for a few hours while the Migraine runs its course. Medications used for rescue include:
- acetaminophen compounds: acetaminophen with codeine, oxycodone, or hydrocodone such as Vicodin, Percocet, Tylenol #3
- antinausea medications: prochlorperazine (Compazine), promethazine (Phenergan), metoclopramide (Reglan), and ondansetron (Zofran)
- butalbital compounds: Fiorinal, Fioricet, etc. (with or without codeine)
- muscle relaxants: carisoprodol (Soma), tizanidine (Zanaflex), baclofen (Lioresal), baclofen (Lioresal)
- NSAIDs: indomethacin (Indocin) ketorolac (Toradol), ketoprofen (Orudis), meloxicam (Mobic)
- Opioids: butorphanol (Stadol), hydromorphone (Dilaudid), meperidine (Demerol), nalbuphine (Nubain) tramadol (Ultram)
Most doctors reserve opioids and barbiturates (such as butalbital) as treatments of last resort because research has shown that any use of these medications increases the risk of Migraine becoming chronic, and reduces the likelihood of chronic Migraine being reduced to episodic.
Depending on what we need and our doctors’ preferences, rescue medications are available in various forms – oral, nasal spray, suppository, and injectable. Nausea, vomiting, diarrhea, and how quickly the different forms take effect can all play a role in selecting which form to use.
Preventive, abortive, and rescue medications all have their uses, and a good Migraine management protocol includes all three. We should have a plan for what to do, what to take, and when to take it for when we get a Migraine. Our doctors should be willing to help us with this plan. If your doctor isn’t, it may well be time for a new doctor.