Key Concepts for acute treatment: 

  • Goal is return to function or at least decrease in symptoms
  • Try different options with your health care provider 
  • Record results on your diary
  • Treat early, it will increase your success rate 
  • Combine NSAID + triptan if severe attacks
  • If you have nausea, use specific medications for it 
  • Use other options than pills for severe attacks (nasal sprays, injections etc)
  • May use different options for attacks of different severity
  • Avoid overuse, if you are at risk consider prevention 
  • Avoid opioids, they should be only a last resort

MedicationBrand namesHow they workSide effects
AnalgesicsAcetaminophen
Paracetamol 
TylenolProbably block inflammationUsually well tolerated Overdose may lead to death Overuse may lead to more headaches
NSAIDsIbuprofen
Diclofenac
Ketorolac
Naproxen 
ASA
Advil,
Motrin
Cambia,
Voltaren
Toradol
Aleve
Aspirin
Block COX enzyme, decrease prostaglandins = less inflammationGastric irritation, bleeds, ulcers Hypertension Small risk of heart disease
TriptansAlmotriptan
Eletriptan
Frovatriptan
Naratriptan
Rizatriptan
Sumatripan
Zolmitriptan
Axert
Relpax
Frova
Amerge
Maxalt
Imitrex
Zomig
Act on the serotonin system (stimulates 5HT 1b-d receptors) Blocks release of CGRPIncrease in headache Nausea Chest pressure Fatigue 
DHEDihydro
ergotamine
Migranal
DHE vial
Act on the serotonin systemNausea
Cramps
Hypertension
CombinationsMix of acetaminophen, NSAID, caffeine, codeine, barbituratesExcedrin Fiorinal Tylenol 1-2-3 Depends on contentDepends on content
High risk of overuse 
OpioidsMorphine
Codeine
Hydromorphone Oxycodone Meperidine
Statex Codeine Dilaudid Supeudol DemerolAct on opioid receptors in the pain networksNausea Somnolence Constipation
High risk of overuse headache Addiction 
Anti-nauseaDimenhydrinate Metoclopramide ProchloperazineGravol Maxeran Stemetil Anti-histamine
Anti-dopamine
Somnolence Restlessness Dystonic reactions
SteroidsDexamethasone PrednisoneDecadron
Act on steroid receptorsInsomnia, hypertension,
fluid retention

** Cannabinoids are not listed as there is currently no evidence on their effect to treat migraine attacks (See this post). More research is needed. 

** Neuromodulation devices can be used to treat migraine attacks and are reviewed in another section.

REFERENCES

Mayans L, Walling A. Acute Migraine Headache: Treatment Strategies. Am Fam Physician. 2018;97(4):243-51.

Worthington I, Pringsheim T, Gawel MJ, Gladstone J, Cooper P, Dilli E, et al. Canadian Headache Society Guideline: acute drug therapy for migraine headache. Can J Neurol Sci. 2013;40(5 Suppl 3):S1-s80.

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