Migraine Preventive, Abortive, and Rescue Medications

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.

Most of us know what preventive medications are for and that they’re taken daily, but I still see a fair amount of confusion about abortive and rescue medications.

Let’s review the three purposes of Migraine medications and what types of medications are used for these purposes:

Preventive Medications

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:

  1. divalproex sodium (brand names Depakote, Depakote ER), a neuronal stabilizing agent, aka anticonvulsant, originally developed for seizure disorders
  2. propranolol (brand names Inderal, Inderal LA), which is a beta blocker originally developed for heart disease and hypertension
  3. timolol (brand name Blocadren), which is another beta blocker
  4. topiramate (brand name Topamax), which is another neuronal stabilizing agent

There is also one medication approved by the FDA for the treatment of chronic Migraineonabotulinumtoxin A (Botox). Botox is not FDA approved for the treatment of episodic Migraine.


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)
  • antidepressants
    • 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

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

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.

Summary

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.

Related information

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Migraine.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Comments

View Comments (13)
  • AmyBabee
    5 years ago

    Thanks Terry. I am more enlightened now. I will actually print this and take it with me to my first appmt with the pain specialist so I can refer to it for clarification, because I will definitely have a lot of questions to ask him.

  • Teri-Robert author
    5 years ago

    You’re very welcome, Amy. Glad it’s going to be helpful to you.

  • merrie
    5 years ago

    Teri,
    Do you think tramadol would a good short term option for me? I have tried all the triptans in the last three months. They almost all gave me chest pain, and did not relieve the migraine. I am currently prescribed fioricet, but as it doesn’t work I have stopped taking it this last couple of months unless I am desperate and wishing it would work. Pointless I know but sometimes at least I feel like I have taken some action, even if it doesn’t work. I tried the indomethacin yesterday as an acute treatment, no such luck. It just gave me stomach cramps, plus I had a migraine, which had worsened by this morning to epic proportions. I barely made it through work. Hubby drove me in, as I have a tendency to do bad things when I have a bad migraine, like accidentally drive over lawns or median strips straight into traffic because I can’t focus and my visions blurry. Anyway. Made it through with just anti nauseous med. But barely. And my district came to talk with me about upcoming reviews today. Sure I made a great impression. Sorry for the ramble, just frustrated. Hopefully will get in to the specialist soon. Federal went through, now just waiting on an appointment. In the mean time looking for something to help while I wait.

  • merrie
    5 years ago

    The federal word was supposed to be referral…stupid auto correct!

  • merrie
    5 years ago

    Tried indomethacin for an acute treatment today, nothing. The other option my Dr recommended was tramadol, which he described as a less risky nsaid but you have in the opioid category, so which is it? Just wondering. I have taken tramadol nd for endometriosis pain and it didn’t work much.

  • zippy36
    5 years ago

    I have also tried tramadol and it does nothing for me. I too now am curious. I thought it was a nsaid too.

  • Teri-Robert author
    5 years ago

    merrie,

    Tramadol is an opioid, technically an opioid agonist, in the same category as morphine. You can find more info at

  • Janet
    5 years ago

    How effective, if you know, is adderall in migraine prevention. I’ve been on pretty much everything else in the past 37 years….I’d greatly hesitate because our daughter became addicted and abused this drug and she almost lost her life …

    Blessings
    Janet

  • Janet
    5 years ago

    Thank you..your articles are always informative…still struggling and can’t get past two days without an abortive…since DHE failed 16 months ago…I’ve been winging it…not all that well. At the time of my hospitalization for DHE I was cold turkeyed from all preventatives and rescue meds…it was HORRIFIC!

    Praying for better days and I do keep informed..thanks to migraine.com and AHMA.

    Blessings
    Janet

  • michellespeer
    5 years ago

    I have been using Dr. Buckholz book for awhile now and have seen the most dramatic drop in migraines that I have ever seen in my life. The diet is one key, but I’d say even bigger than that is that I use the abortive and rescue medicines just opposite of what you discussed. When you take the abortive medications too much you end up getting rebound migraines. It was probably the hardest thing I’ve ever done, but it’s been the best thing for me, to stop taking the abortive (triptans) so much. Now I’m able to take them only about 1-2 times a month when I actually get a migraine. (I was having 10-15 migraines days a month before, now down to about 2). The rescue medications (aleve, ibuprofen) I take a couple times a week when I have a slight feeling of a migraine coming on. Actually these never used to work for me at all, but I think they work now because I’m not popping triptans like candy anymore.

  • Teri-Robert author
    5 years ago

    Michelle,

    There are a few things to remember about that book:
    1. It’s old as far as Migraine information goes. A great deal has been learned since it was written.
    2. Even when it was written, quite a bit of what he wrote was not what was being proven in studies.
    3. He says in the intro to the book that parts of it are his own theories.

    Yes, you can get medication overuse headache (MOH), aka rebound, from triptans, BUT you can also get them from the rescue medications. The trick is to not take acute medications more that two or three days a week. Take a look at http://migraine.com/blog/living-with-migraine/help-how-can-i-not-overuse-migraine-medications/

  • zippy36
    5 years ago

    Thank you for the info. This article is very informative and helpful…

  • Teri-Robert author
    5 years ago

    You’re very welcome. Glad to be able to help! 🙂

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