Migraine medicines

There a number of medicines available to help ease the symptoms of migraine.

Migraine treatment is aimed at stopping symptoms and preventing future attacks. It may take time to work out the best treatment for you. You may need to try different types or combinations of medicines before you find the most effective ones. 

On this page, you will find the following information:

Paracetamol

Paracetamol can be an effective pain reliever, especially for mild symptoms. It is used alone or in combination with another medicine, such as paracetamol and ibuprofen (Maxigesic®, Nuromol®).

Paracetamol is mostly a safe option if you don't take more than 4 grams per day. Too much paracetamol can harm your liver and may cause severe liver damage. Accidental overdose can happen because many different products include paracetamol, so if you are taking more than one medication, make sure you check the label for ingredients. Read more about paracetamol

Note: Paracetamol should not be taken for headache on more than 15 days per month. Frequent use can cause medication-overuse headache (see below). 

Non-steroidal anti-inflammatory drugs (NSAIDs)

Examples: ibuprofendiclofenacnaproxen and aspirin

NSAIDs are most effective if taken at the first signs of a migraine. It's best not to wait until the headache worsens before taking NSAIDs. Some people find one NSAID to be more effective than another, so it's worth trying different ones to find the one that is best for you. 

NSAIDs usually need a prescription from your doctor, although you can buy some in small quantities over the counter in smaller doses. There are risks associated with taking NSAIDs. Check with your doctor or pharmacist whether NSAIDs are a safe option for you. Read more about NSAIDs.

Note: NSAIDs should not be taken for headache on more than 15 days per month. Frequent use can cause medication-overuse headache (see below). 

What are triptans?

Examples: rizatriptan, sumatriptan tablets and sumatriptan injection

Triptans are a specific pain reliever for migraine headaches. Triptans are most effective if taken at the first signs of a migraine attack while the pain is still mild. They should be taken early during a migraine attack but not during the aura phase. They work by releasing a chemical in your brain called serotonin. This causes the blood vessels around your brain to contract (narrow). This reverses the dilating (widening) of blood vessels that's believed to be part of the migraine process.

Common side effects of triptans include warm sensations, tightness, tingling, flushing and feelings of heaviness in the face, limbs or chest. Some people also experience nausea, dry mouth and drowsiness. These side effects are usually mild and improve on their own. Read more about triptans.

Medicines for nausea (feeling sick) or vomiting (being sick)

Examples: metoclopramide, domperidone and prochlorperazine

These medicines are called anti-sickness medicines or antiemetics. They can be helpful to treat migraine even if you don't experience nausea or vomiting. These are prescribed by your doctor and can be used together with other pain relievers and triptans. Seek medical advice before taking anti-sickness medicines as they are not suitable for some people.

As with pain relievers, anti-sickness medicines work better if taken as soon as your migraine symptoms begin. They usually come in the form as tablets, but are also available as a suppository.

Avoid opioids for migraine

Many people with migraine are given strong painkillers, called opioids, to treat migraines. Examples of opioid painkillers available in New Zealand include codeine, tramadol, morphine, oxycodone, fentanyl and pethidine. However, opioids are not preferred to relieve migraines for the following reasons:

  • They can make headaches worse. Using opioids for migraine can cause more headaches and chronic migraines than you had to begin with. This is called ‘medication-overuse headache’. It is possible with all pain medicines, but is more likely with opioids.
  • They are not as effective as other migraine medicines. There are medicines that are better than opioids to reduce the number of migraines you have and how severe they are. This includes medicines called triptans, which work directly on the blood vessels in your head to relieve the pain from migraine.
  • They can be harmful. Opioids are strong medicines that may cause you harm, including dependence and addiction. Opioids can cause serious withdrawal symptoms if you stop taking them suddenly. People who use high doses for a long time may need to go to hospital while they stop using them. Opioids, even at low doses, can make you feel sleepy or dizzy. Other side effects include constipation and nausea. Using them for a long time can lower your sex drive and cause depression and sleep problems.

Opioids may be needed in some instances.

  • In some people, the migraine-specific medicines don’t work. Opioid painkillers may be a short-term ‘rescue’ option for these people. In this situation, you should not take opioids more than 9 days per month. At the same time, you and your doctor should continue to focus on other strategies to help you prevent and manage your migraines. Long-term follow-up is needed to make sure you do not develop complications from taking opioids.
  • If you have certain medical conditions, such as some heart diseases, or if you are pregnant, you may not be able to take the migraine-specific medicine. Talk to your doctor if this applies to you.

Read more: Treating migraine headaches – some drugs should rarely be used Choose Wisely, NZ

What is medication-overuse headache?

Medication-overuse (rebound) headache can occur if you use too many pain relief medicines to treat headaches and migraines. It may feel like a tension-type headache or migraine-like attack. Headaches often improve within 2 months of withdrawal of the overused medicine, but can feel worse before improvement is seen.

To avoid this:

  • triptans should not be used for more than 10 days per month
  • paracetamol and NSAIDs should not be taken for headache on more than 15 days per month.

Medicines to prevent migraines

Preventive medicines are taken daily to prevent migraine attacks from happening. They are not used to treat an acute attack. Medicines to prevent migraines are an option if you:

  • have at least 2 attacks a month
  • have significant disability even with suitable treatment for migraine
  • cannot take suitable treatment for migraine attacks. 

Preventative medicines help to reduce the severity and length of attacks and how often you get them, reduce disruption to your daily activities and reduce overuse of acute medicines. They must be taken every day to be effective. They may take a few weeks to start working. 

Many different preventive medicines are available. Which one is best for you depends on things such as:

  • other medical conditions you have, including high blood pressure, asthma, diabetes or pregnancy (among others)
  • potential side effects of the medicine
  • your response to preventive medicines if you've used them before.
Examples of medicines to prevent migraine
Beta-blockers
  • Examples include propranolol, atenolol, nadolol, metoprolol and timolol.
  • These medicines are mostly used to treat high blood pressure but they do have other uses.
  • Common side effects include tiredness and depression.
  • Read more about beta-blockers
Antidepressants
  • Examples include amitriptyline and nortriptyline.
  • These medicines are also used to treat depression and other conditions.
  • Common side effects include weight gain, dry mouth, feeling sleepy, tiredness and decreased libido (sex drive).
 Anti-epileptics
  • Examples include topiramate, sodium valproate and gabapentin.
  • These medicines are mostly used to treat epilepsy but they have many other uses.
  • Common side effects include weight gain or loss, drowsiness and skin rash.
  • Sodium valproate must not be taken during pregnancy.
Erenumab (also called Aimovig)
  • Erenumab belongs to a group of medicines called anti-CGRP antibodies. CGRP stands for calcitonin gene-related peptide.
  • It works by blocking the activity of the CGRP molecule, which has been linked to migraine.
  • Erenumab is given as a monthly injection in people with at least 4 migraine days per month.
  • Common side effects include constipation and allergic reaction. 
  • Note: Erenumab is currently not funded in New Zealand.  

References

  1. Treatment of acute migraine NZ Formulary
  2. Prophylaxis of migraine NZ Formulary
  3. The role of triptans in the treatment of migraine in adults BPAC, 2014, NZ 
Credits: Sandra Ponen, Pharmacist. Reviewed By: Angela Lambie, Pharmacist, Auckland; Dr Helen Kenealy, geriatrician and general physician, CMDHB Last reviewed: 17 Aug 2021