Medicines for migraine

Medicines for migraines fall into a few categories.

Category
Pain relieving medicines (for immediate relief)
  • paracetamol
  • NSAIDs such as ibuprofen, diclofenac and naproxen
  • triptans
Medicines for nausea (feeling sick) or vomiting (being sick)
  • metoclopramide
  • domperidone
  • prochlorperazine
Medicines to prevent migraines
  • propranolol, atenolol, nadolol, metoprolol, timolol
  • amitriptyline, nortriptyline
  • topiramate, sodium valproate, gabapentin

Pain-relieving medicines

These are taken during migraine attacks, for immediate relief, to stop symptoms that have already begun. Pain relievers are most effective if taken at the first signs of a migraine attack, as this gives it time to absorb into your bloodstream and ease your symptoms. The choice of pain relief depends on the severity of your migraine and your response to the treatment. A usual approach is:

  • Step 1: paracetamol and/or NSAIDs
  • Step 2: triptans
  • Step 3: combination treatment with a triptan and an NSAID.

Paracetamol

Paracetamol can be an effective pain reliever, especially for mild symptoms, either when used alone or in combination with other medicines, such as:

  • paracetamol + ibuprofen (Maxigesic®, Nuromol®)
  • paracetamol + caffeine (Panadol Extra®, Panadol Extra with Optizorb®)
  • paracetamol + codeine (Panadeine ®, Panadeine Extra ®, Panadeine Plus ®).

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.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Examples of NSAIDs include ibuprofendiclofenac and naproxen. Some people find one form of NSAID 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.

  • The main risk is stomach problems such as indigestion, stomach upset and stomach ulcers. 
  • Extra care is needed if you have high blood pressure, high cholesterol, or diabetes or if your kidneys do not work very well, you smoke, have cardiovascular disease (heart disease) or vomiting and diarrhoea. NSAIDs increase the chance of a heart attack or stroke, which can lead to death.
  • Some medicines interact with NSAIDs, and they should not be taken together.

Check with your doctor or pharmacist if NSAIDs are a safe option for you. 

Triptans

If paracetamol or NSAIDs don't help to relieve your migraine symptoms, you may be prescribed triptan medications such as rizatriptan, sumatriptan or zolmitriptan. These are available as tablets, injections and nasal sprays.

Triptans are a specific pain reliever for migraine headaches. They work by releasing a chemical in the brain called serotonin, and this causes the blood vessels around the 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, including sumatriptan tabletssumatriptan injection and rizatriptan.

Avoid opioids - choose wisely

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. Opioids are not preferred to relieve migraines because:

  • 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 medications, but is more likely with opioids.
  • They are not as effective as other migraine medicines: there are other medicines that can reduce the number of migraines you have and how severe they are—better than opioids. 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 medications which 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 be in the hospital in order to 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 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 about Treating migraine headaches: some drugs should rarely be used Choosing Wisely, NZ

Caution – medication overuse headache

Medication overuse (rebound) headache can happen from using too many pain relief medicines to treat headaches and migraines. It may feel like 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 for nausea (feeling sick) or vomiting (being sick)

Examples include metoclopramide, domeperidone 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.

Preventive medicines

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

Many different preventive medications are available, and the choice depends on many things such as:

  • other medical conditions that 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   Description
Beta-blockers 
  • 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
  • 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
 
  • 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.

References

  1. Treatment of acute migraine New Zealand Medicines Formulary
  2. Prophylaxis of migraine New Zealand Medicines Formulary
  3. The role of triptans in the treatment of migraine in adults BPAC July 2014, NZ