Acute migraine treatments relieve migraine attacks that are in progress, easing pain, nausea, and light sensitivity. These include over-the-counter pain relievers, triptans, ditans, gepants, dihydroergotamine, steroids (usually for attacks that don’t respond to other treatment) and antinausea medications.
Others are preventive, meaning that people taking them aim to reduce how many attacks they have and how severe they are. People who have frequent or severe migraine attacks that disrupt daily life may be candidates for preventive migraine medications.
Preventive medications include antiseizure medications, beta-blockers, calcium channel blockers, CGRP monoclonal antibodies, and certain antidepressants.
People may need to try different options to settle on a preventive drug that works for them, and it may take a few months to start reducing migraine attacks.
Low doses can help people limit side effects while finding a treatment that works for them.
Over-the-Counter (OTC) Pain Relievers
This category includes nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin, as well as acetaminophen (Tylenol). A combination drug containing aspirin, acetaminophen, and caffeine (Excedrin Migraine) may be effective at reducing the pain associated with mild to moderate migraine. But it’s not as effective for severe attacks.
If your doctor recommends NSAIDs or products containing aspirin, these drugs have links to side effects such as ulcers and gastrointestinal bleeding. Daily use might lead to medication-overuse headaches.
Triptans
Triptans are also known as 5-HT1B/1D receptor agonists because they block the pain pathways in the brain by binding to specific serotonin receptors on neurons.
Doctors often prescribe them if other migraine therapies haven’t been successful. Seven triptans are available, including:
- eletriptan (Relpax)
- rizatriptan (Maxalt)
- zolmitriptan (Zomig)
- frovatriptan (Frova)
- naratriptan (Amerge)
- sumatriptan (Imitrex)
- almotriptan
According to Everyday Health network site Migriane Again, triptans come in many forms, including oral pills, nasal sprays, nasal powder, and injections. Non-oral methods (e.g., nasal sprays and injections) can be more effective for people experiencing the migraine symptom of nausea or vomiting as the digestive system tends to slow during an attack.
Common side effects of triptans include nausea, dizziness, drowsiness, and muscle tingling, numbness, and weakness. Because one of their actions is to constrict blood vessels, doctors don’t recommend triptans for people at high risk for a stroke or heart attack.
Ergots
Ergots interact with the same brain receptors as triptans. However, doctors often prescribe triptans instead of ergots, as more research supports the effectiveness of triptans for treating migraine attacks.
An ergot called dihydroergotamine (Migranal, Trudhesa) may be used when triptans aren’t having the desired effect on pain.
Dihydroergotamine is most effective when delivered intravenously (IV), which requires a medical professional to administer the dose. It’s also available as a self-injection and as a nasal spray.
Gepants
CGRP is a peptide (or short chain of amino acids) in the brain and nervous system that causes blood vessel dilation and plays a role in transmitting pain. Research shows that blood and saliva levels of CGRP increase during migraine attacks.
CGRP antagonists, sometimes referred to as “gepants,” prevent CGRP from binding to receptors in various cell types in the brain.
FDA-approved gepants include:
- atogepant (Qulipta)
- rimegepant (Nurtec ODT)
- ubrogepant (Ubrelvy)
- zavegepant (Zavzpret)
Different drugs require different dosages. For example, atogepant is available in 10-milligram (mg), 30 mg, and 60 mg doses.
Zavgepant is a nasal spray available as a single spray (10 mg) in one nostril, as needed. The maximum dose in 24 hours is one 10 mg spray.
In 2023, atogepant also received approval as a preventive treatment for chronic migraine based on a study in which participants had roughly seven fewer migraine days over 12 weeks on either 30 mg twice a day or 60 mg once a day compared with a placebo.
5-HT1F Receptor Agonists (Ditans)
Also known as ditans, 5-HT1F receptor agonists selectively bind to certain serotonin receptors on trigeminal neurons, blocking the transmission of pain in the trigeminal nerve system.
The trigeminal nerve is a complex nerve responsible for sensation in the face and movement of the jaw muscles.
Activation of the trigeminal nucleus, located in the brain stem, might be a key stage in a migraine attack’s development.
Lasmiditan (Reyvow) is the only drug in this class, and it has approval as an acute migraine treatment.
Antiemetics
If your migraine attacks include nausea and vomiting, your doctor may prescribe an oral antinausea drug, also known as an antiemetic, to take along with a pain-relieving medication. Antiemetics used for migraine relief include:
- chlorpromazine
- prochlorperazine (Compro)
- metoclopramide (Reglan)
- droperidol (Inapsine)
Metoclopramide increases muscle contractions in the upper digestive tract to speed up the rate at which food in the stomach moves to the small intestine.
Chlorpromazine,
droperidol,
and prochlorperazine,
in contrast, control nausea by blocking chemicals in the brain linked to vomiting.
Antihypertensive Medications
People typically use beta-blockers to manage high blood pressure and coronary artery disease, but doctors also commonly prescribe them to prevent migraine attacks.
Examples of beta-blockers that may help treat migraine include:
- propranolol (Inderal LA or Innopran XL)
- metoprolol tartrate (Lopressor)
- timolol (Betimol)
More research is necessary to understand how beta-blockers work for people with migraine.
Side effects might include depression, insomnia, nausea, and extreme tiredness.
Calcium channel blockers are another blood pressure medication that may help prevent migraine attacks.
One common example is verapamil (Calan, Verelan).
Antidepressants
Tricyclic antidepressants work by changing the levels of serotonin and other chemicals in your brain. To date, amitriptyline (Elavil) is the only tricyclic antidepressant proven to prevent migraine attacks. Side effects can include dry mouth, constipation, weight gain, sexual dysfunction, and others.
Antiseizure Drugs
Certain antiseizure or antiepileptic drugs, including divalproex sodium (Depakote) and topiramate (Topamax), have been shown to reduce the frequency of migraine attacks. They’re available as tablets, capsules, and sprinkle capsules, or capsules full of small beads of medication designed to be sprinkled over soft foods.
The exact way in which these medications prevent migraine attacks is unclear. You would take them as a daily or twice-daily dose.
Antiseizure drugs have significant side effects, including nausea, fatigue, unexpected weight changes, hair loss, dizziness, diarrhea, and concentration problems.
Doctors recommend against using them if you’re pregnant or plan to become pregnant.
Botox
The U.S. Food and Drug Administration (FDA) has approved onabotulinumtoxinA (Botox) to treat adults with chronic migraine. Doctors inject the drug into around 31 areas in the forehead and neck, where it reduces muscle contractions and blocks pain signals in the nerves for around 12 weeks.
Botox injections can reduce the number of migraine attacks by around half. They commonly cause neck soreness as a temporary side effect, which may feel better after applying an ice pack.
You’ll have injections about every three months, and you may not feel the benefits until your second or third treatment. In the meantime, you can take other migraine medications without the risk of harmful interactions.
CGRP Monoclonal Antibodies
CGRP monoclonal antibodies are lab-made proteins that specifically target CGRP in the body to reduce its effect on pain and inflammation.
CGRP antibody drugs include:
- eptinezumab (Vyepti)
- erenumab (Aimovig)
- fremanezumab (Ajovy)
- galcanezumab (Emgality)
CGRP monoclonal antibodies are a preventive migraine treatment.
A review of data published in 2023 concluded that they reduced the number of migraine days compared with placebo in both episodic and chronic migraine.
People receive CGRP antibodies either as an intravenous (IV) infusion once every three months, or as a monthly injection.
Each monoclonal antibody carries a risk of different side effects. For example, erenumab may lead to constipation, ulcers, higher blood pressure, and hair loss. Eptinezumab might cause a scratchy throat or stuffy nose.
Corticosteroids, or Steroids
Doctors may prescribe steroid medications, including methylprednisolone and dexamethasone, to treat a migraine headache that hasn’t responded to other treatments or that has lasted more than 72 hours, known as status migrainosus. Most studies on steroids for migraine relief have shown that these drugs are most useful for migraine prevention, leading to milder migraine attacks.
Doctors prescribe steroids, especially dexamethasone, in conjunction with other types of migraine drugs, such as triptans, to improve pain relief. They may administer steroids by IV in a hospital or clinic.
Steroids are only suitable for short-term use as they have a risk of side effects including insomnia and high blood sugar.
Nerve Blocks for Acute Migraine Pain Relief
A nerve block involves injecting small amounts of a numbing medicine such as lidocaine or bupivacaine into the base of the skull, over the eyes, or in the temple to block pain signals from the nerves. Nerve blocks can relieve pain within minutes, and the effects may last for days, weeks, or even months.
A doctor can also inject a nerve block into myofascial trigger points, which may relieve pain in these hypersensitive areas. Myofascial trigger points are nodules in skeletal muscle that are painful under pressure that can also cause pain in other areas of the body.
Pressing on myofascial trigger points may provoke a migraine attack in some people with migraine.
Emergency Medication for Intractable Migraine
Doctors usually refer to a severe migraine attack that lasts for more than 72 hours and doesn’t respond to a person’s usual acute therapies as an intractable migraine, or status migrainosus. It’s often necessary to seek additional treatment in the emergency department in those cases, where a number of drugs can be administered intravenously to help break the headache cycle.
Those drugs may include:
- Antiepileptics
- Triptans
- NSAIDs
- Steroids
- Muscle relaxants
- Antipsychotic medications
Intractable migraine can be debilitating and worrying, and you might not be able to think clearly when you get to the ER. Consider asking your regular doctor to write down and sign an emergency migraine treatment plan for you to bring with you to the hospital or urgent care center. This can help you access the medications that are most effective for you.
Ideally, your emergency migraine treatment plan should include:
- Your diagnosis
- Any relevant information about your medical history
- Your doctor’s recommendations for the safest and most effective medications for you
- Your doctor’s signature and contact information
