The medications discussed here are symptomatic or acute migraine medications which are used to treat individual migraine attacks (See this post). They can be divided into broad categories: Simple analgesics, NSAIDs, triptans, ergot derivatives, anti-emetics, opioids, and combination products. 

** Cannabinoids are not listed as there is currently no evidence of 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 in Canada 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 production of prostaglandins which are natural substances in the body that cause pain. It is not considered an anti-inflammatory medication. 
Is this a good option for migraine?  It may work for mild migraine attacks but is rarely sufficient.
Are there risks? Taken regularly (15 days per month or more), acetaminophen can cause medication overuse headaches. High doses of acetaminophen can cause liver damage.
Are there side effects? Acetaminophen is usually well tolerated. High doses on a regular basis may cause tinnitus
Comments and interesting facts Acetaminophen 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 blood clotting and gastric function. 
Are they good options for migraine?  Yes. NSAIDs are the first-line option for migraine attacks.
Are there risks NSAIDs can irritate the stomach and cause ulcers and bleeds. They can also increase blood pressure and have been associated with a risk of heart disease (though the risk is very small). They should be avoided or used cautiously in people with kidney disease.
Are there side effects? Stomachupset, some people report sleepiness
Comments and interesting facts The response to NSAIDs may vary. One person may respond to ibuprofen better than naproxen or the reverse. NSAIDs also have different durations of action. Ibuprofen is taken every 4-6 hours, Naproxen lasts longer and can be taken every 12 hours.
More interesting facts Aspirin 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, naratriptan, 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.
Although they can be life changing, some
people do not seem to be helped by triptans. As responses can vary, it is important to try a few different ones before abandoning triptans
Are there risks Triptans  constrict blood vessels and should not be used in people with a history of stroke or heart disease. Triptans should not be used for specific migraine types like hemiplegic migraine and basilar migraine. They can be used for migraine with a typical aura. Some triptan may be used during pregnancy after a careful discussion of risks and benefits. 
Are there side effects? Side effects may limit the use of triptans even if they are effective. Fatigue, nausea, chest pressure, and an increase in headache have been reported. 
Comments and interesting facts Triptans 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 are a bit different 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 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 must be avoided in pregnancy. 
Are there side effects?  Nausea, vomiting, diarrhea, leg cramps, and high blood pressure have been reported.
Comments and interesting facts Ergotamine 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  act through different mechanisms. Some act on dopamine, others on serotonin.
Are they a good option for migraine? Anti-emetics may decrease the nausea and vomiting associated with migraine and allow other medications such as NSAIDs or triptans to be taken and not thrown up.
Are there risks Some anti-emetics acting on dopamine can produce muscle spasms and feelings of restlessness.
Are there side effects? Sleepiness
Comments and interesting facts Anti-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 to block pain. There are different receptors (mu, kappa, and delta) with different effects
Are they a good option for migraine? NO. Opioids should be avoided in people with migraine since they carry a high risk of causing chronic migraine and medication overuse headache. Only physicians experienced in the management of headache should prescribe opioids to people with migraine.
Are there risks There are risks including worsening migraine, addiction, and respiratory failure. 
Are there side effects? Constipation, sedation, myoclonus (spasms or jumpy muscles).
Comments and interesting facts Opioids seem to decrease the effectiveness of migraine preventives and neuromodulation devices

Combination products

Many combination products are sold over-the-counter (without a prescription)  in Canada. Most will combine acetaminophen or aspirin with caffeine and sometimes a low dose of codeine. 

Fiorinal, used frequently for migraine management in the 1980s, contains barbiturates, and anxiolytics that may help through a calming effect, but can be addictive. 

Combination analgesics may be perceived as very benign drugs, but caffeineopiates 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. 

For people with migraine who experience a partial benefit with NSAIDs and/or triptans alone, combining the two medications may lead to more effective migraine treatment. In Canada, there is a product available by prescription that combines sumatriptan and naproxen in a single pill. For more information on this approach see here.

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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