How your migraines are treated will depend on the frequency and severity of attacks. People who have a headache several times per year often respond well to nonprescription pain relievers. However, other therapies should be considered when headaches are disabling enough to interfere with usual activities and pain relievers don't work well.
There are two types of medications to treat migraines — drugs that are taken when a headache starts (called abortive medications) and drugs that are taken every day to prevent migraines (called preventive medications). The decision of whether to take a daily preventive medication or abortive medications is a personal choice. In the past, daily preventive medication was prescribed when a person had an average of two or more migraines per month. Today, reasons for prescribing preventive medication include:
Infrequent attacks that don't respond well to abortive medications
Attacks that occur too often
Overuse of abortive medications or common pain relievers
Adverse reactions to abortive medications
Cost, including costs related to missing work
Migraines associated with unusual neurological symptoms (complicated migraines)
When possible, an abortive medication should be taken immediately after an aura or migraine headache starts. This can be a challenge for people with frequent auras or headaches because overusing abortive medications can lead to chronic daily headache, a headache disorder that describes headaches that occur day after day without a specific cause or diagnosis. Several nonprescription drugs and some relatively inexpensive prescription drugs are available. Aspirin, ibuprofen (Advil, Motrin and other brand names) or naproxen (Aleve) taken at the earliest warning may be enough to stop a full-blown headache. Drug combinations often work better than drugs with a single active ingredient. One popular remedy for migraines is the combination of aspirin, acetaminophen and caffeine (Excedrin) taken once or twice per month when symptoms occur.
Other medications require a prescription. Examples include isometheptene (Midrin and other brand names); medications called triptans, such as sumatriptan (Imitrex), naratriptan (Amerge), zolmitriptan (Zomig) and rizatriptan (Maxalt); and medications called ergotamines, such as sublingual ergotamine (Ergomar) and dihydroergotamine (Migranal). In addition, people who experience nausea with or without vomiting also can take an anti-nausea pill or suppository.
If the headache becomes more intense and does not respond to one or two doses of an abortive medication, pain relievers can be used to lessen the discomfort. The type and amount of pain reliever you should take varies depending on how you responded to the medication previously and how much other medications you took when the headache started.
Many drugs are listed as potentially useful to prevent recurrent migraine attacks. The following are prescribed most frequently:
Beta-blockers — Propranolol (Inderal) and nadolol (Corgard) have a good track record of being safe and effective. Metoprolol (Lopressor) and atenolol (Tenormin) are reasonable alternatives.
Calcium channel blockers — Verapamil (Calan, Isoptin) is a popular choice. However, the medical evidence supporting its effectiveness is not as strong compared to other drugs.
Anticonvulsants — Of the drugs in this class, valproate (Depakote and other brand names) and topiramate (Topamax) have the best evidence to support using it for prevention.
Tricyclic antidepressants — These medications are very effective, but often have troublesome side effects such as sedation, blurred vision, dry mouth and constipation. The first choice is often amitriptyline (Elavil). Venlafaxine (Effexor) and others also can be tried.
Some people with migraine have very frequent headaches, sometimes every day. This form of migraine, called chronic migraine, is difficult to treat. The newest treatment is Botox (onabotulinumtoxinA). The doctor gives multiple injections around the head and neck once every 12 weeks. It is approved for people that experience migraine headaches more than 14 days per month.
Preventive medications (except for Botox injections) need to be taken every day to be effective. In choosing which medication to try first, you and your doctor will evaluate the benefits and the possible side effects. For example, if you have both high blood pressure and migraine, a calcium channel blocker or beta-blocker might be the best choice to treat both. However, if you have asthma, your doctor might not prescribe a beta-blocker.
Don't be discouraged if your first choice of preventive medication does not meet your expectations. You and your doctor may need to try three or four different strategies to find the best one for you.