Migraine treatment

What is the best treatment for migraines?

Most people with migraine can find a treatment that works reasonably well for most attacks. However, children, and pregnant and breastfeeding women have a limited choice as many anti-migraine and anti-sickness medicines are not suitable for them.

If you have frequent or severe attacks of migraine, another option is to take a medicine to prevent migraines. Here you will find information on migraine medicines to treat and prevent migraine.

Medicines for treatment of migraine attacks

There are four types of medicines that are commonly used to treat migraine attacks:

• Ordinary painkillers - eg, paracetamol.

• Anti-inflammatory painkillers - eg, aspirin, ibuprofen.

• Anti-sickness medicines - eg, domperidone, prochlorperazine.

• Triptans - eg, almotriptan, naratriptan, sumatriptan, zolmitriptan.

Painkillers

Paracetamol and aspirin both work well for many migraine attacks. Take a dose as early as possible after symptoms begin. If you take painkillers early enough, they often reduce the severity of the headache pain, or stop it completely. A lot of people do not take a painkiller until a headache becomes really bad. This is often too late for the painkiller to work well.

Strictly speaking, aspirin is an anti-inflammatory painkiller (see below). Recently, aspirin has fallen from favour for the treatment of many painful conditions. However, as a cure for migraines, it often works very well and is worth a try.

A review of research studies published in 2010 (see under 'Further Reading and References', below) confirms the place of aspirin. The review concluded that aspirin (at full dose) either takes away migraine pain, or greatly reduces the pain, within two hours in more than half of the people who take it.

Take the full dose of painkiller. For an adult this means 900 mg aspirin (usually three 300 mg tablets) or 1000 mg of paracetamol (usually two 500 mg tablets). Repeat the dose in four hours if necessary. Soluble tablets are probably best, as they are absorbed more quickly than solid tablets.

It is best not to use codeine and medicines containing codeine, such as co-codamol when treating migraines. This is because codeine can make feeling sick (nausea) and being sick (vomiting) worse, which can make migraine worse. They are also more likely than paracetamol or aspirin to cause a condition called medication-overuse headache (also called 'medication-induced headache') if you use them frequently (see below).

Anti-inflammatory painkillers

Anti-inflammatory painkillers (including aspirin) probably work better than paracetamol to ease migraine. You can buy aspirin or ibuprofen at pharmacies or obtain them on prescription. Other types such as diclofenac, naproxen, or tolfenamic acid need a prescription. Also, some points about anti-inflammatories include:

• It may be best to take the maximum allowed dose as soon as the headache begins rather than taking smaller doses.

• Ideally, take an anti-inflammatory medicine with some food or milk. This plays a role in reducing the risk of developing a stomach upset which some people have with these medicines. However, this may not be possible if you feel sick (nausea) or are sick (vomit).

• One brand of ibuprofen dissolves and disperses in the mouth, and is swallowed with saliva. This may be easier to take than other tablets if you feel sick.

• One brand of diclofenac comes as a suppository. This may be useful if you usually vomit with a migraine attack.

• Some people with asthma, high blood pressure, kidney failure, or heart failure may not be able to take anti-inflammatory painkillers.

• For a full list of cautions and possible side-effects for your particular medicine, see the leaflet that comes in the medicine packet.

Treating nausea and vomiting due to a migraine

Migraine attacks may cause a feeling of sickness (nausea) or cause you to actually be sick (vomit). The nausea makes it harder for your body to absorb migraine tablets into your body. If you take painkillers, they may remain in your stomach and not work well if you feel sick. You may even vomit the tablets back. Tips that may help include:

• Use soluble (dissolvable) painkillers. These are absorbed more quickly from your stomach and are likely to work better.

• As mentioned, one brand of diclofenac comes as a suppository. This may be useful if you usually vomit with a migraine.

• You can take an anti-sickness medicine in addition to painkillers. A doctor may prescribe one - for example, domperidone, prochlorperazine or metoclopramide.

• Like painkillers, anti-sickness medicines work best if you take them as soon as possible after symptoms begin.

• An anti-sickness medicine, domperidone, is available as a suppository if you feel very sick or vomit during migraine attacks.

• Prochlorperazine comes in a buccal form which dissolves between the gum and cheek. This can be useful if you feel sick and do not wish to swallow a tablet.

The National Institute for Health and Care Excellence (NICE) has updated its guidance on using metoclopramide or prochlorperazine for people with migraine. They recommend that your doctor discuss the risks and benefits of these medicines with you before issuing them.

Combinations of medicines

Some brands of migraine tablets contain both a painkiller and an anti-sickness medicine - for example, Paramax®, and MigraMax®. They may be convenient. However, the dose of each part (constituent) may not suit everyone, or be strong enough. You may prefer to take painkillers and anti-sickness medicines separately so that you can control the dose of each, and you know exactly what you are taking.

What are triptans?

A triptan is an alternative if painkillers or anti-inflammatory painkillers do not help much. Triptans are a group (class) of medicines that are used to ease the symptoms of a migraine attack or cluster headache. They include almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, and eptinezumab (vyepti), and come in various different brand names. They are also known as 5-HT1 agonists. They come as migraine tablets (both to be swallowed and in dispersible form), as an injection and as nasal spray preparations. You need a prescription for most triptans, but you can buy sumatriptan from pharmacies.

How do triptans work?

Triptans are not painkillers. Triptans work by imitating the action of a brain chemical called 5-hydroxytryptamine (5-HT). 5-HT is also known as serotonin. 5-HT gives instruction to cells by attaching to specific sites (receptors) on the outside of them, rather like a password triggering a computer programme or a key opening a lock. One of the effects 5-HT has is to cause widened (dilated) blood vessels to narrow (constrict). For this reason, do not take a triptan too early in an attack of migraine. (This is unlike painkillers described above which should be taken as early as possible.) They may also reduce the release of other brain chemicals that occurs during a migraine attack.

How do you take a triptan?

You should take the first dose when the headache (pain) is just beginning to develop, but not before this stage. That is, do not take it if you are experiencing a migraine with aura symptomsi and do not take it to prevent one from coming on. Studies have shown that they do not work as well if taken too early. Triptans taken by mouth are designed to work rapidly - within an hour or so. Injected triptans usually work in 10-15 minutes.

After you have taken the first dose:

• If the triptan worked to relieve your headache but then the headache returned later, you can repeat the dose after 2-4 hours. Each triptan has a maximum daily dose that you should not exceed. This will be written on the packet.

• If the triptan did not work at all, a second dose is unlikely to work, so do not take a second dose. The exception to this is zolmitriptan (2.5 mg), where a second dose may be tried after two hours even if the first dose did not work. See the patient leaflet that comes in the medicine packet for details.

If a low dose does not work so well, your doctor may prescribe a larger dose. Also, some triptans work in some people and not in others. Therefore, if one triptan does not work, the same one at a higher dose, or a different one, may well do so. In some cases, some people have tried three or more different triptans before finding one that works best for them. However, do not make a judgement after just using a particular triptan once.

The British Association for the Study of Headache (BASH) recommends that you try each triptan for three separate migraine attacks before deciding to change to a different one. Even in people where triptans work well, a triptan does not work for every migraine attack.

The aim is to find the one that works most of the time for you. If the triptan you try doesn't work for you, your doctor may also advise a change in the way in which the medicine is given in some cases. For example, if feeling sick (nausea) or being sick (vomiting) usually occurs during your migraine attack, migraine medication that you don't have to swallow is likely to be more effective for you (see below).

What are the side-effects of triptans?

Read the leaflet in the packet for possible side-effects. If side-effects occur they are usually mild and do not usually last long. The most common include:

• A warm-hot sensation, tightness, tingling, flushing, and feelings of heaviness or pressure in areas such as the face, arms, legs and occasionally the chest. Triptan sensations in the chest can mimic heart pains (angina) and may cause alarm. Whilst these sensations are not usually harmful, if you develop intense chest pain or sensations, you should consult a doctor immediately or go directly to the nearest accident and emergency department (you may need to dial 999/112/911 for an ambulance).

• Some people feeling a little unsteady or dizzy, developing a dry mouth, or feeling sick (nausea).

• Drowsiness which can be caused by sumatriptan. If this occurs, do not do skilled tasks such as driving.

The way side-effects affect different people can vary between the different triptans. So, if one causes unpleasant side-effects, a switch to a different one may be fine.

A migraine attack itself can often cause nausea and being sick (vomiting). This can cause problems in taking triptan tablets. Options to consider if this is a problem include:

• Sumatriptan, which is also available as an injection.

• Rizatriptan and zolmitriptan, which are available as a wafer or as a tablet that disperses in the mouth, and is then swallowed with saliva.

• Zolmitriptan and sumatriptan, which are available as a nasal spray.

• Also, taking an anti-sickness medicine such as domperidone or metoclopramide (see above).

Most people who have migraine can usually find a triptan that works well for most migraine attacks, and where side-effects do not occur or are not too bad. A main problem with triptans is that in about one in four cases, after taking a triptan which clears a headache, the headache returns within the next 48 hours. If this problem tends to happen with you then options to consider are:

• You can take a repeat dose when the headache returns (if the first dose worked). A dose of triptan can be repeated within 2-4 hours (depending on the type). But, make sure you do not exceed the maximum dose recommended over a 24-hour period. For example, total dosage of sumatriptan per 24 hours should not exceed 300 mg as tablets (orally) or 40 mg as a nasal spray (intranasally). NB: if you take frequent doses of a triptan there is a danger that you may get 'rebound' headaches called 'medication-induced headache' (see below).

• Your doctor may consider prescribing naratriptan or eletriptan. Return of the headache is thought to be less common after treatment with these triptans.

• Some people take a short course of an anti-inflammatory painkiller such as diclofenac or tolfenamic acid in the 24-48 hours after the headache goes. This may prevent a return of the headache and reduce the need for a repeat dose of a triptan.

Can I buy triptans over the counter?

Sumatriptan can be bought, without a prescription, from pharmacies, although only after an assessment by the pharmacist. Triptans should only be taken to treat migraine or cluster headache that has been previously diagnosed by your doctor, as there are other causes of headache besides migraine and cluster headache, and you need a diagnosis. The other triptans apart from sumatriptan are only available on prescription.

Who cannot take triptans?

A full list of people who should not take triptans is included with the patient leaflet that comes in the medicine packet. If you are prescribed a triptan, read this to be sure you are safe to take it. In particular, you should not take a triptan:

• If you have uncontrolled high blood pressure (hypertension).

• If you have, or are told you are at high risk of developing, cardiovascular disease (such as angina, or heart attack).

• If you have had a stroke or transient ischaemic attack (TIA).

• If you have coronary vasospasm such as Prinzmetal's angina (this is rare).

• If you are pregnant.

• When breastfeeding, unless you have taken the following into account:

  • Traces of triptans are passed out in breast milk, so they should either be avoided during breastfeeding, or milk should be expressed and discarded for 12-24 hours after taking them (see manufacturer's information).

• Without advice from your doctor if you have certain kidney or liver conditions. A reduced dose is recommended for some triptans if you are affected by one or more of such conditions.

Triptans should not be taken at the same time as migraine treatments containing ergotamine, as the combination of the two could be harmful. (Ergotamine is a migraine medication that is rarely used now.) If you stop taking a triptan you must wait before taking anything containing ergotamine. If you are taking ergotamine you must also wait before taking a triptan. This waiting period varies between 12 and 24 hours, depending on the type of triptan. Speak to your doctor or pharmacist if this applies to you.

There are age restrictions on the use of triptans:

• Children younger than 12 years of age should not usually take triptans. (Triptans are not licensed for children younger than 12 but may occasionally be prescribed by a specialist paediatrician).

• Adolescents (aged 12-18 years) may be prescribed sumatriptan nasal spray (10 mg).

• Triptans are not licensed for people aged over 65 years.

Are triptans safe?

Triptans are usually safe if you do not have any of the medical conditions mentioned above. Because these medicines can cause the constriction of blood vessels, they should not be given to people with heart or blood vessel problems.

If you take triptans too often, you increase your risk of developing medication-induced headache.

What is medication-induced headache?

Medication-induced headache (also called medication-overuse headache or analgesic headache) is caused by taking painkillers or triptans too often for headaches of any kind. It is a common cause of headaches that occur daily, or on most days. About 1 in 50 people develop this problem at some time in their lives. For example:

• You may have a bad spell of tension headaches or migraine attacks, perhaps during a time of stress. You take painkillers or a triptan more often than usual, and for a while. Your body becomes used to the medication. A withdrawal (rebound) headache then develops if you do not take a painkiller or triptan within a day or so of the last dose. You think this is another tension headache or migraine attack, and so you take a further dose of painkiller or triptan. When the effect of each dose wears off, a further withdrawal headache develops, and so on. In time, you may have headaches on most days, or on every day, and you end up taking painkillers or a triptan every day, or on most days.

If you find that you are getting headaches on most days then this may be a cause. See a doctor for advice. Some people who may think they are getting frequent migraine attacks or are developing chronic migraine, are in fact getting medication-induced headache.

See the separate leaflet called Medication-overuse Headache (Medication-induced Headache).

More on combination migraine tablets

If none of the above treatments is useful, there is some evidence to suggest that the combination of sumatriptan (a triptan) plus naproxen (an anti-inflammatory painkiller) works better than either medicine alone. However, it is best to talk it through with your doctor before embarking on these sorts of combinations.

Menstrual migraine treatment

Treatment of each menstrual migraine attack is the same as for any other type of migraine. However, there are treatments that may prevent menstrual migraines from occurring.

Medicines for migraine attacks in children

Many of the medicines used by adults for migraine are not licensed for children. Paracetamol or ibuprofen is suitable and commonly used. Apart from these you must check with your doctor or pharmacist before giving a child any other medicine for migraine.

• Paracetamol or ibuprofen is suitable. Do not use aspirin.

• As regards anti-sickness medicines, domperidone is licensed for children of all ages, and prochlorperazine is licensed for children older than 12 years.

• Triptans are not licensed for children and so should not be used (see above).

Medicines for migraine when pregnant or breastfeeding

Many of the medicines used to treat migraine should not be taken by pregnant or breastfeeding women.

• For relief of a migraine headache:
  

  • Paracetamol is the medicine most commonly used, as it is known to be safe during pregnancy.

  • Ibuprofen is sometimes used but do not take it in the last third of the pregnancy (the third trimester).

  • Aspirin - avoid if you are trying to conceive, early in pregnancy, in the third trimester and whilst breastfeeding.

  • Triptans - should not be taken by pregnant women at all. Triptans can be used during breastfeeding, but milk should be expressed and discarded for 12-24 hours after the dose (see manufacturer's information on the packet).

• For feeling sick (nausea) and being sick (vomiting) - no medicines are licensed in pregnancy. However, occasionally a doctor will prescribe one 'off licence'.

• Medicines used for the prevention of migraine are not recommended for pregnant or breastfeeding women.

Check with your pharmacist or doctor if you are not sure.

How to prevent migraines

You need to take the medicine every day.

Who should take a medicine to prevent migraine attacks?

There is no definite rule. For example, you may wish to consider this option if you have:

• More than two migraine attacks (episodes) per month that cause significant disruption to your life.

• Less frequent, but severe, migraine attacks.

• The need to use a lot of painkillers or triptan medicines to treat migraine attacks.

• Painkillers or triptans for migraine attacks not working very well, or you are unable to take them because of side-effects or other problems.

• Migraine attacks, which are suspected of causing medication-induced headache. You can read more about this in the treatment section of this leaflet. (See also the separate leaflet called Medication-overuse Headache (Medication-induced Headache) which has further details.)

• Menstrual migraine.

Before embarking on preventative treatment, it is probably best to keep a migraine diary for a few months to assess:

• How often and how bad your migraine attacks are.

• Your current use of medication to treat the migraine attacks.

This may help you to decide if preventative treatment is worth a try, and also to help assess if you may have medication-induced headache. See the leaflet called Migraine trigger diary, including a migraine diary that you may like to print out and use.

Which medicines are used to prevent migraine attacks?

NICE has updated its guidance on headache in over-12s. All the changes relate to medication to prevent migraine and the risks they could carry if you become pregnant while taking them. In addition, the MHRA (the body that regulates medications in the UK) has updated its guidance on the use of some medicines used to prevent migraines.

If you are a women who is or might be sexually active and might become pregnant:

• You should not take sodium valproate (a medicine usually used to treat epilepsy).

• If you are offered topiramate (another medicine usually used to treat epilepsy) you must be aware that:

  • Topiramate can be effective in reducing the frequency and severity of migraines.

  • If you are taking topiramate when you are pregnant, there is a risk of birth defects in your baby.

  • Topiramate can make hormonal contraception less effective.

  • It is essential that you use really effective contraception, such as the contraceptive injection, an intrauterine coil or IUS, or a combination of the combined oral contraceptive pill along with a barrier method of contraception.

Beta-blockers

Beta-blockers include propranolol, atenolol, metoprolol, timolol and nadolol. They are commonly used to treat conditions such as angina and high blood pressure. It was first noticed by chance that some people who were treated for angina, who also had migraine, found their migraine attacks (episodes) lessened when on propranolol. It is not clear how they work to prevent migraine. However, beta-blockers are now a common treatment for migraine - most commonly, propranolol. A low dose may work, but the dose can be increased if necessary. Some people cannot take beta-blockers - for example, some people with asthma or peripheral arterial disease.

Anticonvulsants

Medicines called sodium valproate and topiramate are sometimes used. These are classed as anticonvulsants, and are usually used to prevent seizures of epilepsy. However, it was found that they can also prevent migraine attacks. Sodium valproate is not recommended for the prevention of migraines under national guidelines.

Amitriptyline

Amitriptyline is classed as a tricyclic antidepressant. However, it has an anti-migraine action separate to its antidepressant effect. It is not clear how it works for migraine. A low dose is started at first, and can be increased if necessary. Some people cannot take amitriptyline - for example, people who have had a heart attack (myocardial infarction), or have coronary heart disease, arrhythmia, or epilepsy. Note: strictly speaking, amitriptyline is not licensed for preventing migraines. However, in practice, it is commonly used, and many doctors are happy to prescribe it for this purpose.

Flunarizine

This medicine is classed as a calcium-channel blocker. It is used quite a lot in many countries as a medicine to prevent migraine. However, flunarizine is not marketed and is not licensed in the UK. Despite this, it is sometimes specially imported from abroad under the direction of a headache specialist when it is considered worthwhile to try.

Others

Various other medicines have been used for the prevention of migraine attacks. Most have limited evidence regarding their effectiveness or have potentially serious side-effects. However, if all else has failed, a specialist may suggest that you try out one of these. They include pizotifen, gabapentin, calcium-channel blockers, lisinopril, and selective serotonin reuptake inhibitors (SSRIs).

Galcanezumab and erenumab for prevention of migraine

NICE has issued guidance on the use of galcanezumab and erenumab. These are both monoclonal antibodies, which work by blocking the action of a natural substance in the body that causes migraine headaches.

NICE recommends that galcanezumab or erenumab should be considered as an option for preventative treatment for migraine in adults. However, this only applies to people who:

• Have four or more migraine days a month; and

• Have tried at least three preventative drug treatments without success.

It recommends that treatment with galcanezumab and erenumab should only be continued for more than three months if the number of migraines does not drop by at least half (for people with fewer than 15 headache days a month) or by at least a third (for people with at least 15 headache days a month).

Fremanezumab for preventing migraine
Fremanezumab is also a monoclonal antibody, which works in a similar way to galcanezumab and erenumab. NICE has issued guidance (see Further Reading below) recommending that fremanezumab should be considered as a treatment for preventing migraine for people who fall into the category above. Their recommendations for deciding if fremanezumab should be continued are also the same as above.

Some points about medicines to prevent migraine attacks

• You need to take the medicine every day.

• It is unlikely to stop migraine attacks (episodes) completely. However, the number and severity of attacks are often much reduced by a preventative medicine. It is useful for you to keep a migraine diary to monitor how well a medicine is working.

• It may take 1-3 months for maximum benefit. Therefore, if it does not seem to work at first, do persevere for a while before giving up.

• It is a common type of practice to take one of these medicines for 4-6 months. After this, it is common to stop it to see if it is still needed. It can be restarted again if necessary.

• If a migraine attack occurs, you can still take painkillers or a triptan in addition to the preventative medicine.

• It is worth trying a different medicine if the first one you try does not help.

• Read the leaflet in the medicine packet for a list of cautions and possible side-effects.

What are the treatment options to prevent menstrual migraine?

Medications used to treat menstrual migraine are the same as those used to treat other forms of migraine. However, your doctor may recommend other treatments to be take regularly, in order to prevent or reduce the severity and frequency of menstrual migraines.

To find out more, see the separate leaflet called Migraine Triggered by Periods.

Botulinum toxin (Botox®) injections to prevent migraine

In July 2010 the Medicines and Healthcare products Regulatory Agency (MHRA) licensed the use of botulinum toxin injections for the prevention of migraine. This decision was based on research studies that seemed to show it to be an effective treatment at reducing the number of migraine attacks (episodes).

Treatment consists of up to five courses of treatment with botulinum toxin injections every 12 weeks. The injections are given into muscles around the head and neck. It is not clear how this treatment may work for migraine. Botulinum toxin relaxes muscles but it may also have some sort of action to block pain signals. The theory is that these actions may have an effect of stopping a migraine headache from being triggered.

In 2012, guidelines were issued by NICE on this treatment. NICE recommends botulinum toxin type A as a possible treatment for preventing headaches in some adults with persistent (chronic) migraine. The criteria set down by NICE for people who may be considered for this treatment are:

• If you have chronic migraine (that is, you have headaches on at least 15 days each month, with migraine on at least eight of these days); and

• You have already tried at least three different medicine treatments to prevent your chronic migraine headaches, but these have not worked; and

• You are not taking too many painkillers or using them too often.

Also, treatment should be stopped if:

• The number of days you have a chronic migraine headache each month hasn't reduced by at least 30% after two courses of botulinum toxin type A treatment; or

• Your chronic migraine changes to episodic migraine (that is, you have fewer than 15 days with headaches each month) for three months in a row.

Note: botulinum toxin injections are also used for cosmetic purposes - for example, as a treatment to smooth out wrinkles. However, for the treatment of migraine the injections need to be in specific sites around the head and neck muscles. Therefore, to prevent migraine attacks, it should only be administered by people trained in its use for this purpose.