Key Concepts for acute treatment: 

  • The goal is to return to function or at least decrease symptoms
  • Try different options with your healthcare provider 
  • Record results in 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
  Medication Brand names How they work Side effects
Analgesics Acetaminophen
Paracetamol 		 Tylenol Probably block inflammation Usually,  well-tolerated Overdose may lead to death Overuse may lead to more headaches
NSAIDs Ibuprofen
Diclofenac
Ketorolac
Naproxen 
ASA		 Advil,
Motrin
Cambia,
Voltaren
Toradol
Aleve
Aspirin		 Block COX enzyme, decrease prostaglandins = less inflammation Stomach irritation, and, ulcers High blood pressure Small risk of heart disease
Triptans Almotriptan
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 CGRP Increase in headache Nausea Chest pressure Fatigue 

Triptan/NSAID combination

 

 

 

 

 

 

 

DHE

sumatriptan and naproxen

 

 

 

 

 

 

 

 

Dihydro
ergotamine

Suvexxl

 

 

 

 

 

 

 

 

 

Migranal
DHE vial

Combined mechanism:
Block COX enzyme, decrease prostaglandins = less inflammation (NSAID)

Act on the serotonin system (stimulates 5HT 1b-d receptors) Blocks release of CGRP (triptan)

 

Act on the serotonin system

Stomach irritation and ulcers
High blood pressure
Small risk of heart disease
Chest Pressure
Increase in headache Nausea
Fatigue 

 

 

 

 

Nausea
Cramps
High blood pressure

 

 
Combinations Mix of acetaminophen, NSAID, caffeine, codeine, barbiturates Excedrin Fiorinal Tylenol 1-2-3 Depends on content Depends on content
High risk of medication overuse headache
Opioids Morphine
Codeine
Hydromorphone Oxycodone Meperidine		 Statex Codeine Dilaudid Supeudol Demerol Act on opioid receptors in the pain networks Nausea Sleepiness Constipation
High risk of medication overuse headache Addiction
Anti-nausea Dimenhydrinate Metoclopramide Prochlorperazine Gravol Maxeran Stemetil  Anti-histamine
Anti-dopamine		 Sleepiness Restlessness Muscle spasms
Steroids Dexamethasone Prednisone Decadron Act on steroid receptors Insomnia, high blood pressure,
fluid retention

** Cannabinoids are not listed as there is currently no evidence of 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.

** New molecules not yet available in Canada like gepants and ditans will be discussed in the future. 

 

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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