Your migraine attacks just won’t break with one medication? Try two! Some migraine attacks are difficult to treat. The migraine attack is a chemical and electrical storm in the brain that leads to pain and a wide variety of accompanying symptoms (See this post). 

The key options for the acute treatment of migraine are anti-inflammatories or NSAIDs and triptans (See this post). 

Why would it be best to take two medications instead of one? 

NSAIDs and triptans have different chemical mechanisms. The NSAIDs work on the inflammation (prostaglandin system to be exact), and the triptans on the serotonin system AND on the CGRP system. Therefore, their actions combined offer a better chance of success. 

Is it dangerous to take two medications at the same time? 

Every person is different, but unless you have contra-indications to either medication, you can safely combine them. 

Is there more risk of medication overuse if I combine triptans and NSAIDs? 

The key factor for the overuse phenomenon is the number of days per month that you use acute medications (See this post). Remember that if your treatment is successful, you may end up with less days of migraine per month. For example, your attack may last only one day instead of three. 

I have been warned about the risk of overuse with «combination analgesics» like Fiorinal. What are those?

Combination analgesics usually contain either acetaminophen or aspirin, codeine and caffeine. Another famous compound, Fiorinal, also contains barbiturates. These medications are linked with a high risk of chronification, mostly because of the opioids and barbiturates, and also because some people tend to see them as «benign drugs» and use them often, even if they do not work very well. 

Are there medications that contain a triptan and an NSAID at the same time? 

Yes. In the United States, a combination of sumatriptan and naproxen exists, it is called Treximet. It is expected to be available in Canada under the name Suvvex. 

Can I use other medications, for example acetaminophen and anti-nausea drugs? 

In theory, you can. This being said, acetaminophen is not a very powerful treatment for migraine and rarely adds a great benefit. Anti-nausea drugs (Gravol, Stemetil, Metonia) may help you to control the nausea and avoid vomiting, so that your other medication are better absorbed. (See this post)

Remember: you do not have to combine all the time! 

Most migraine patients have different types of attacks. Some are milder, some are very severe. If you know from experience which attack is coming, you can adapt your treatment to fit your attack severity. Is it going to be a mild attack? Maybe an NSAID is enough. But if all your warning signs are there that this will be a severe attack, it is best to use the strongest combination. 

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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