Key Concepts for acute treatment:
- The goal is to return to function or at least a decrease symptoms
- Try different options with your care provider
- Record results in your diary
- Treat early, it will increase your success rate
- For severe attacks, discuss combinations with your care provider
- If you have nausea, use specific medications for it
- Use other options than pills for severe attacks (nasal sprays, injections, etc.)
- Natural techniques (hot, cold, mint rollers, acupressure [1], breathing exercises) can help
- May use different options for attacks of different severity
- Avoid overuse, if you are at risk consider prevention
- Gepants do not lead to medication overuse headache
- Cannabis is better avoided for migraine [2] treatment until more research is available
- Avoid opioids, they should be only a last resort
| Medication | Brand names | How they work | Side effects [3] | |
| Analgesics | Acetaminophen Paracetamol |
Tylenol | Probably block inflammation [4] | Usually well-tolerated. Overdose may lead to death. Overuse may lead to more headaches. |
| Anti-inflammatories NSAIDs | Ibuprofen Diclofenac Ketorolac Naproxen ASA |
Advil, Motrin Cambia, Voltaren Toradol Aleve Aspirin |
Block COX enzyme, decrease prostaglandins = less inflammation [4] | Stomach irritation, ulcers. High blood pressure [5]. Small risk of heart disease. |
| Triptans [6] | Almotriptan Eletriptan Frovatriptan Naratriptan Rizatriptan Sumatriptan [7] 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 |
| Combination | sumatriptan and naproxen | Suvexxl | The combination of sumatriptan and naproxen allows to take one tablet instead of two | Side effects of sumatriptan and naproxen may occur |
| DHE | Dihydroergotamine | Migranal DHE vial for injection |
Act on the serotonin system | Nausea Cramps Hypertension |
| Combinations | Mix of acetaminophen, NSAID, caffeine [8], 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 | Somnolence, Restlessness, Distonic reactions |
| Steroids | Dexamethasone, Prednisone | Decadron | Act on steroid receptors | Insomnia [9], hypertension, fluid retention |
** Cannabinoids are not listed as there is currently no evidence of their effect to treat migraine [2] attacks (See this post [10]). More research is needed.
** Neuromodulation devices can be used to treat migraine attacks and are reviewed in another section [11].
** New molecules not yet available in Canada like gepants and ditans will be discussed in the future.
REFERENCES
Mayans L, Walling A. Acute Migraine [2] 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 [12] for migraine headache. Can J Neurol Sci. 2013;40(5 Suppl 3):S1-s80.
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