Abortive Therapy
Initial abortive therapy for mild to moderate migraine headaches includes non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil or Motrin) and naproxen (Aleve or Naprosyn), and other non-prescription pain medications (also known as analgesics) such as aspirin and acetaminophen (Tylenol). Another medication available, without a prescription, that some find effective is a combination of aspirin, acetaminophen, and caffeine (Exedrine or Exedrine Migraine).
If non-prescription medications are not effective, several prescription medications are available to relieve migraines. Among the most commonly prescribed are selective serotonin agonists, commonly known as "triptans". Designed specifically for migraine treatment, seven triptans are available in the United States. They are almotriptan (Axert), eletriptan (Relpax), frovatriptan (Frova), naratriptan (Amerge), rizatriptan (Maxalt), sumatriptan (Imitrex), and zolmitriptan (Zomig). Triptans are generally prescribed for moderate to severe migraines with or without auras, and they also may work when other previous treatments have failed. They come in several different dosage forms that may include injections and nasal spray, as well as traditional tablets to take by mouth. In addition, rizatriptan and zolmitriptan are available in rapidly-dissolving tablets that melt quickly for fast absorption when placed on the tongue. Although triptans work in similar ways, one may be more effective than another for certain individuals. Therefore, individuals who do not find relief from one triptan may want to consider trying another triptan before switching to a completely different drug class. Triptans should not be used by individuals with heart disease or uncontrolled high blood pressure. And, as with other headache medications, overuse of triptans may lead to rebound headaches.
Ergot derivatives are a second-line prescription option for treating moderate to severe migraine headaches that do not respond to non-prescription treatment or triptans. Ergot derivatives are most effective in dosage forms that reach the bloodstream quickly. Sublingual tablets that dissolve quickly under the tongue (Ergomar), injections (dihydroergotamine mesylate, DHE-45), and nasal sprays (dihydroergotamine, Migranal) are rapidly-acting ergot derivatives. Although they are effective for many individuals, taking ergot derivatives usually requires close monitoring by a healthcare provider. They may be habit-forming and they may cause numerous side effects, including abdominal cramps, dizziness, dry mouth, and nausea. Individuals who experience potentially serious side effects such as leg cramps or coldness, numbness or pain in the hands or feet while taking an ergot derivative should contact a doctor immediately.
Combinations of isometheptene mucate, dichloralphenazone, and acetaminophen (Midrin, Duradrin) or combinations of aspirin or acetaminophen with butalbital, codeine, or both (Fiorinal, Fioricet) may also be used as abortive treatment for migraine headaches. Caution should be used because of the potential for dependence associated with these drugs.
Many individuals who suffer from migraines also have nausea, and some evidence suggests that stomach contents are poorly absorbed into the body during a migraine attack. Consequently, taking medications by mouth may not be as effective as using other routes of administration, such as rectal suppositories or injected medications.
Prophylactic/Preventive Therapy
One possible way to prevent migraines is to avoid triggers. Eating regular, healthy meals, limiting caffeine, eliminating other food triggers, and getting plenty of exercise may help to prevent migraines from occurring. Keeping a headache diary may facilitate identification of triggers (see the Helping Yourself section to learn more about headache diaries). If medication is needed, it usually has to be taken regularly. Only certain individuals are candidates for prophylactic therapy with medication. These are individuals whose migraines cause severe disruptions in normal activity despite treatment, and those who have frequent migraines requiring prescription medication (at least twice weekly) which puts them at risk for developing rebound headaches. For these persons, several prescription options are available.
Tricyclic antidepressants (TCAs), such as amitriptyline, may be effective migraine prevention for some individuals, especially those with underlying depression, insomnia, or tension headaches. Although amitriptyline is generally accepted to be the most effective TCA for prevention of headaches, other TCAs such as doxepin (Sinequan), imipramine (Tofranil), nortriptyline (Pamelor), and protriptyline (Vivactil) have also shown some effectiveness. TCAs should be taken at night because they can cause sedation. Other possible side effects from TCAs may include an unpleasant taste in the mouth, and dry eyes, mouth, and skin. Individuals with glaucoma or an enlarged prostate should use caution when taking TCAs due to the increased risk of side effects.
Other prescription medications commonly used for migraine prevention include oral beta-blockers, such as atenolol (Tenormin), metoprolol (Lopressor), propranolol (Inderal), and timolol (Blocadren); and calcium channel blockers, such as verapamil (Calan, Isoptin, Verelan). Common side effects of beta-blockers may include decreased blood pressure, depression, impotence, and lethargy. Common side effects of calcium channel blockers are decreased blood pressure, constipation, and leg swelling.
Some medications used primarily to treat epilepsy may also decrease the frequency, duration, and/or severity of migraine headaches. Valproic acid (Depakene), divalproex sodium (Depakote), and topiramate (Topamax) are anti-epileptics that are also approved for migraine prophylaxis. Tremor, weight gain, and hair loss are common side effects of these drugs. Rarely, they may cause liver damage. Therefore, symptoms of nausea, vomiting, and yellowing of eyes or skin should be brought to the attention of a doctor immediately. To decrease the risk of liver damage, blood tests should be performed periodically as long as anti-epileptic medications are taken.
Another drug occasionally used to prevent migraine headaches is methysergide maleate (Sansert). Methysergide maleate has been discontinued in the United States, but it may still be available in other countries. Its use must be limited due to the relatively high number of side effects that are associated with taking it. Dizziness, drowsiness, flushing, heartburn, insomnia, and stomach upset may all be caused by methysergide maleate. Long-term use may result in heart or lung changes. Methysergide maleate should be taken no longer than 6 months at a time, doses should be decreased gradually, and at least 3 to 4 weeks must be allowed before starting it again. Individuals taking methysergide maleate need to be supervised closely by a healthcare professional that is familiar with its use.
Non-drug Therapy
Resting in a cool, dark, quiet room is effective treatment for some migraine sufferers. Others find relief from an ice pack or cool water on their foreheads.
