The medications to be discussed here are the symptomatic migraine medications which are used to treat individual migraine attacks (See this post). They can be divided into four broad categories: Analgesics, NSAIDs, Triptans and ergot derivatives, Anti-emetics and Opioids.  

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

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

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

The simple analgesics

Examples (generics)Acetaminophen
Paracetamol
Examples (brand names)Tylenol
How does it work?Acetaminophen blocks the synthesis of prostaglandins but is not considered an anti-inflammatory
Is this a good option for migraine?It may work for mild migraines but is rarely sufficient.
Are there risks?A high dose of acetaminophen can be deadly through liver toxicity.Taken regularly (15 days per month or more), acetaminophen can cause medication overuse headache. 
Are there side effects?Acetaminophen is usually well tolerated. High doses on a regular basis may cause tinnitus. 
Comments and interesting factsAcetaminophen comes from nature! Components related to acetaminophen are found in the cinchona bark.

The non-steroidal anti-inflammatory drugs or NSAIDs

Examples (generics)Ibuprofen, naproxen, acetylsalicylic acid, diclofenac, ketorolac, nabumetone, mefenamic acid
Examples (brand names)Advil, Motrin, Aleve, Aspirin, Toradol, Cambia, Voltaren, Ponstan
How do they work?NSAIDs block the enzyme COX that produces inflammatory substances but also molecules involved in coagulation and gastric function. 
Are they good options for migraine?Yes. NSAIDs are a first line option for migraine attacks. 
Are there risksNSAIDs can irritate the stomach and cause ulcers and bleeds. They also increase the blood pressure and have been associated with a risk of cardiovascular disease (though the risk is very small).
Are there side effects?Gastric upset, some people report somnolence
Comments and interesting factsThe response to NSAIDs may vary. One person may respond to ibuprofen better than naproxen or the reverseNSAIDs also have different durations of action. Ibuprofen is taken every 4-6 hours, Naproxen last longer and must be taken every 12 hours.
More interesting factsAspirin comes from the willow bark. White willow was used in Antiquity for its anti-fever properties. If you use natural products, remember that white willow (salix alba) is like aspirin. 

Triptans

Examples (generics)Almotriptan, eletriptan, frovatriptan, rizatriptan, sumatriptan, zolmitriptan
Examples (brand names)Axert, Amerge, Frova, Maxalt, Relpax, Imitrex, Zomig
How do they work?Triptans act on the serotonin receptors. We know now that they also block the release of CGRP. 
Are they a good option for migraine?Triptans are an option if NSAIDs fail to control migraine attacks.
They can be life changing.
Some people do not seem to be helped by triptans, though it’s important to try a few different ones before abandoning this class. 
Are there risksTriptans do constrict blood vessels.
They should not be used in people with a history of stroke or heart disease. The risk is small though. Triptans should not be used for specific migraine types like hemiplegic migraine and basilar migraine. They can be used for migraine with typical aura. Some triptan may be used during pregnancy after a careful discussion. 
Are there side effects?Side effects may limit the use of triptans even if they are effective. Fatigue, nausea, chest pressure, and  increase of the headache are reported. 
Comments and interesting factsTriptans are not painkillers. They are used only for migraine and a few related less common headache types.When the first triptan was commercialized in 1992, results were so impressive that many psychiatric theories of migraine were put into question. 

Ergot derivatives

Examples (generics)Ergotamine, dihydroergotamine (DHE)
Examples (brand names)Cafergot, Migranal (DHE nasal spray)
How do they work?Ergot derivatives act on serotonin receptors, but a bit differently than the triptans. 
Are they a good option for migraine?Ergotamine and DHE should not be used as first or even second line therapy. They have more side effects and risks than triptans. They  should be prescribed by experienced physicians. DHE has the great advantage of not causing medication overuse headache. 
Are there risks Ergot derivatives have more effect on arteries and veins than triptans. They should never be used in people with any vascular disease and they are strictly contra-indicated in pregnancy. 
Are there side effects?Nausea, vomiting, diarrhea, leg cramps and hypertension. 
Comments and interesting factsErgotamine was inspired by rye ergot (claviceps purpurea), a fungus that grows on rye. (See this post)

The anti-emetics

Examples (generics)Dimenhydrinate, odansetron, chlorpromazine, metoclopramide
Examples (brand names)Gravol, Zofran, Stemetil, Maxeran, Metonia
How do they work?Anti-emetics may act through different mechanisms. Some act on dopamine, other on serotonin. 
Are they a good option for migraine?Anti-emetics may decrease the nausea and vomiting associated with migraine and allow the medication to be taken and not thrown up. 
Are there risksSome anti-emetics acting on dopamine can produce spasms and restlessness. 
Are there side effects?Somnolence
Comments and interesting factsAnti-emetics acting on dopamine are used in the intra-venous form in the emergency department to treat refractory migraine attacks (status migrainosus). The oral forms do not have this effect.

Opioids

Examples (generics)Codeine, hydromorphone, morphine, oxycodone, tramadol, burprenorphine
Examples (brand names)Statex, Dilaudid, Supeudol, Oxycocet, Zytram, Butrans
How do they work?Opioids act on the morphine receptors in our brain. There are different receptors (mu, kappa, delta) with different effects. 
Are they a good option for migraine?NO. Opioids should be avoided in migraine patients since they carry a high risk of chronification and medication overuse headache. Only physicians experienced in the management of headache should prescribe opioids to migraine patients. 
Are there risks There are risks including chronification, addiction and respiratory failure. 
Are there side effects?Constipation, sedation, myoclonus (spasms or jumpy muscles).
Comments and interesting factsOpioids seem to decrease the effectiveness of preventives and neuromodulation devices. 

The combinations

Many combinations are sold over-the-counter in Canada. Most will combine acetaminophen or aspirin combined with caffeine and sometimes a low dose of codeine. 

Fiorinal, often used for migraine management in the 1980s, contains barbiturates, anxiolytics that may help through a calming effect, but is very addictive. 

Combination analgesic may be perceived as very benign drugs, but caffeine, opiates and barbiturates all have risks and side effects that should be taken into account. The risk of medication overuse headache is quite high with these compounds. 

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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