Migraine Medication Overview
Migraine is a primary headache disorder, meaning that it’s not caused by another illness. Drug treatments for migraine vary from person to person. They are given to either stop and attack or to prevent attacks. Patients with frequent and severe headaches often require both approaches. We hope this Migraine Medication Overview will help you.
Acute medication is given to relieve or stop an attack.
Preventative Medication is given to reduce the frequency and severity of attacks.
It’s important to realise that medications won’t prevent attacks altogether and won’t cure migraine.
The choice of treatment will depend on;
- The severity and frequency of any headaches
- The effect that migraine has on a person
- Associated symptoms
- Other illnesses that the patient may have
- The patient’s medical history.
Acute treatment should be taken as early as possible, e.g. at the first sign or feeling of an attack.
Analgesics are painkillers. They don’t attack the cause of the pain but work by reducing the person’s perception of it, numbing the area affected by pain.
- Non-Steroidal Anti-Inflammatory drugs (NSAIDs)
However, over use of these drugs can lead to dependency or medication overuse headache, and too much caffeine can be a trigger for some people.
Analgesics work better for mild to moderate episodic attacks. If nausea is one of your migraine symptoms then the soluble forms of the drugs may be the best for you.
An ‘acute treatment cocktail’ is now considered as ‘best practice’, e.g. 1 Paracetamol + 1 NSAID + 1 Triptan + 1 Anti Emetic – See the chart under the MOH section of this article
Medications that contain codeine should be avoided.
The main purpose of anti-emetics is to fight nausea and sickness. They have no direct effect on migraine, but are used if nausea is a major part of your attack. Anti-Emetics also help to absorb other medication more quickly.
Metoclopramide (Prescription) and Domperidone (OTC) are the two common anti-emetics. Some tablets contain a combination of painkiller and anti-emetic medication e.g. Migraleve (OTC) and Paramax (Prescription).
Triptans (or 5-HT agonists) are the migraine specific, prescription-only (with one exception) drugs that became available in the 1990s.
There are six Triptan drugs available in Ireland at the time of publication. These are;
- Almotriptan (Almogran)
- Frovatriptan (Frovex)
- Sumatriptan (Imigran (Prescription) / Sumatran Relief – (OTC)
- Zolmitriptan (Zomig)
- Naratriptan (Naraverg)
- Eletriptan (Relpax)
The main advantages of these drugs are that they’re fast-acting and can work even if taken up to two hours into an attack. As well as tablets, other formats are available;
- Tablets that dissolve on the tongue
- Nasal sprays
Triptans should be taken as early as possible in the headache phase of an attack. If you have migraine with aura, you shouldn’t expect the Triptan to affect the aura symptoms. Triptans only act on the headache part of the migraine.
Triptans are not prescribed for children, pregnant women, people over the age of 65 or people with conditions such as high blood pressure. Medication overuse headache is also possible with Triptans.
The goal of preventative treatments is to reduce the frequency and the severity of your migraine attacks. They are prescribed;
- If you suffer from more than two or three attacks per month
- If your attacks are particularly severe or disabling
- To break the cycle of attacks
- If your attacks follow a regular pattern
- If you suffer from rare forms of migraine such as basilar or hemiplegic migraine
Adherence to medication plans is very important
Preventatives are taken every day for a period of 9 – 18 months, starting at a low dose and slowly building up every few weeks. They rarely prevent attacks altogether but help in about 50-60% of cases which means that it’s likely you will experience at some benefit.
One of the biggest problems with preventative treatment is that people often take it incorrectly, either by missing days or by not taking the treatment for a long enough period of time.
A period of three month is needed before the benefits of a medication can be seen. For this reason, it’s important to complete the course of treatment prescribed and, in the manner prescribed.
If side effects are causing you problems, let your doctor know as he/she can change the medication or lower the dosage.
There’s a wide selection of medications that can be prescribed by your GP/Neurologist as a preventative. The most common include:
1. Beta Blockers
Beta Blockers are used to treat angina and high blood pressure; however they have been shown to be helpful in preventing migraine. Examples of beta-blockers used for migraine are propranolol, metoprolol, and atenolol.
Sodium Valproate (Epilim)* Gabapentin and Topiramate originally used to prevent seizures are used in small doses to treat migraine
* The European Medicines Agency recently imposed tighter restrictions on the use of Sodium Valproate (Epilim) for female children, adolescents, women of childbearing age and pregnant women. Please consult your doctor if in any doubt – See www.migraine.ie for further information. Some anti-convulsant medications may also affect the use of contraceptive medication.
Anti-Depressants affect the serotonin receptors in the central nervous system. Many people are offended when they’re prescribed an anti-depressant as they believe that their doctor doesn’t understand their condition, but just as beta blockers can be prescribed for you even though you don’t have high blood pressure, antidepressants are prescribed in the same way.
- Tricyclic Anti-depressants are the type usually used to treat migraine. The most common is Amitriptyline,
- The newer SSRI (selective serotonin reuptake inhibitor) anti-depressants are not usually prescribed for migraine because they can aggravate headaches in some people.
4. Calcium Channel Blockers
These drugs are also used for blood pressure in some people, but have also been found to be helpful for migraine. Flunarizine is used as a migraine preventative and Verapamil is used in the treatment of Cluster Headache.
5. 5-HT Antagonists
5-HT Antagonists interfere with the action of serotonin, which is known to play a large part in migraine attacks. Pizotifen is a widely used drug which has been shown to reduce headache frequency and severity in up to 50- 70% of cases.
6. Onabotulinum Toxin-A (Botox)
Botox is given for migraine under what are called the PREEMPT Protocols which are specific to migraine prevention. Treatment with Botox involves 30-32 small injections around the head, neck and shoulders. Treatment takes about 15-20 minutes.
Botox for Migraine is not currently covered under most Irish health insurance and costs between €500 and €900 per session with the possibility of 4 sessions a year. It must be done by a doctor/specialist nurse trained in giving Botox for migraine.
7. Greater Occipital Nerve (GON) Block
The GON Block is an injection of local anaesthetic, and is sometimes mixed with a dose of steroid. A small needle is used to give an injection into the back of the neck. The back of the skull and top of the head may be numb for a while from the local anaesthetic. It must be given by a specialist doctor/nurse/pain specialist
- Is a substance released in the trigeminal nerve
- Spikes during migraine
- Dilates blood vessels
- Degrades mast cells (cells which control inflammation during allergic reactions)
- Creates an inflammatory fluid in the blood vessels
There are 2 main approaches for targeting CGRP in migraine: monoclonal antibodies given by injection to prevent attacks and small absorbable tablets for both acute and preventative treatment.
Medications act by either blocking a receptor called the calcitonin gene-related peptide receptor (CGRP-R), or sticking to the substance (CGRP) and not allowing it to reach the nerve.
There are currently two anti-CGRP medications in use in Ireland at the moment but only under a ‘compassionate-need’ basis – Erenumab (Aimovig) and Fremanezumab (Ajovy)
- Erenumab is available in an auto-injector and taken once a month
- Fremanezumab is currently in syringe form and can be taken once a month or a double dose quarterly
Some Tips about your Prescription Medication:
- Complete the course of treatment prescribed and in the manner prescribed
- Treat your attacks as early as possible
- Always bring your medication with you wherever you go
- Use your Migraine Diary to record how the drugs work
- Don’t overuse painkillers as this can lead to Medication Overuse Headache (see below)
- Report any side effects to your doctor/pharmacist immediately.
Medication Overuse Headache
When people with episodic migraine begin to get more frequent and severe headaches, they often increase their use of acute pain medication to deal with it. However, if taken too often, pain-relief medication can itself lead to a type of chronic daily headache called Medication Overuse Headache (MOH)
The body gets used to the medication, then craves more. When the drugs wear off, a headache is triggered which causes the person pain and leads him/her to take more medication. This leads to a vicious cycle of taking medication to get rid of a headache that is caused by taking the medication.
The headache is usually on both sides of the head, with pain that gets worse and then eases. It’s associated with fatigue, nausea, vomiting, and restlessness. Preventative medications will be less successful in treating migraine if the person has MOH.
MOH only affects Migraineurs. See this chart to help avoid MOH
Common Questions about Migraine Medication to Ask your Doctor/Pharmacist
If you’re prescribed a medication to treat your migraine, you should be able to understand the basics of the drug, how to take it and what role it has in your treatment. There are certain questions that you might want to ask. The doctor will probably give you most of the information you need, but don’t be afraid to ask questions like;
- What type of medication is it?
- How does the medication work?
- How long will it take to start showing results?
- What are the possible side effects?
- Are there any risks to taking this drug?
- Should I let you know if any side effect starts to occur?
- Must I avoid other medication while on the one being prescribed?
- Am I being started on a low dose?
- What is the next step if this doesn’t work?
- What forms does this medicine come in?
- Is it safe to drive or work while taking this medication?
- What should I know about a medication I am prescribed?
You can also find some of this information on the Patient Information Leaflet enclosed with the medication.
Common Questions about Migraine Medication
Is it safe to take more than one drug to combat a migraine attack?
In general, drugs can be taken together to fight an attack, but only if you carefully follow the guidelines set down by your doctor and the instructions on the pack. There are exceptions to this rule as some drugs may have contraindications so always consult your doctor on this issue.
Your pharmacist can also be a good source of information, and with most now having a consulting room it may be easier to get information from them rather than a new appointment with your GP.
Why is my medication not working?
Migraine is a very individual disorder. While some people get relief with the first drug they try, it can take time to find something that works for others. Always follow the guidelines outlined by your doctor to make sure that you are taking your medication properly before you report it as failed.
Don’t stop taking the medication if it’s not working – talk to your doctor or pharmacist first.
Can I use complementary treatments in conjunction with my medication?
Always check with your doctor before using or attending complementary therapy as some therapies and supplements are contraindicated with some medications and for other disorders. Complementary therapies such as biofeedback, physiotherapy and relaxation therapy are well respected within the medical profession as treatments for migraine.
Always check the credentials of complementary practitioners before treatment and approach the treatment with the same caution that you would with any drug treatment.
What drug-treatments are suitable for children?
Preventative measures such as rest, sleep, diet management (in some cases) and other non-drug treatments are used before medication for children. Keeping a Migraine Diary is also a good management tool for children.
Anti-Emetics such as domperidone are also given to children who feel sick and vomit during an attack. Make sure to consult with your doctor or pharmacist about this. Triptans are not approved for children. Paracetamol can be prescribed for some children, but only under the supervision of a doctor or pharmacist.
The most commonly used preventative drug for children is pizotifen.
What drugs can be taken during pregnancy?
Studies show that migraine improves during pregnancy in the majority of cases, particularly in the second and third trimesters. Not all women will experience this though, so where migraine persists, all non-drug treatments should be tried before considering medication.
Medication can be harmful to the developing foetus, especially in the first three months, so its use should be stopped as soon as you discover that you’re pregnant.
The Occipital Nerve Block may be an option for some women; however this option should only be discussed after all non-medication options have been tried.