A good medication for you is obviously one that quickly stops the migraine pain and other symptoms, and that has few or no side effects for you. For most migraine sufferers, this ends up being one of the NSAIDs, a triptan, or dihydroergotamine DHE.  But how do you get to where you want to go.

There are several approaches to finding the best medication.  One that many headache specialists use is to match the medication to the severity of the patient’s headache attacks.  This has been called the stratified approach, in that the medication is matched to the patient’s headache attack severity.  With this approach, if a person has quite severe migraine headaches that for example put them in bed for a number of hours or almost do so, then the person should probably go on a triptan medication. These tend to be the most effective for severe migraine attacks. DHE would be another option.

On the other hand, if your migraine attacks are quite mild, you may do perfectly well with aspirin, or ibuprofen, or acetaminophen. If your attacks are of moderate severity, and you are able to carry on your activities during them although perhaps with some  difficulty, you may be fine on one of the NSAIDS, like ibuprofen, naproxen, ketorolac, or diclofenac. However, if these are not satisfactory, then you should try a triptan or DHE.

Of course things can be a little more complicated. Some people have attacks of different severity, for example some moderate attacks and some severe attacks. If they can tell in advance what type of headache it is going to be, they can take a NSAID for the moderate attacks, and a triptan for the severe attacks. If they make a mistake, and the NSAID is not up to the job of controlling a particular attack, they can always take the triptan a little later, although of course it may not work quite as well if it is taken later in the headache.

Some physicians use the step approach, and try simple or inexpensive medications first, and then go on to other medications if these don’t work. They may for example ask you to try aspirin or acetaminophen first, then an NSAID, then a combination analgesic, and then perhaps a triptan. With this, it can take some time to find a medication that really works. The disadvantage of this is that some patients become discouraged, stop seeing their doctor, and end up taking relatively ineffective non-prescription medication for many years.

In practice, however, most people with migraine have tried a few things on their own before they see their doctor for help. The doctor therefore is not really starting treatment, but rather changing it, hopefully for the better. Nevertheless, for patients with relatively severe migraine attacks, it is helpful if an effective medication can be found fairly quickly.