Acute medication

Medically reviewed by Dr. Jason Ray, 27 May 2021

Acute medications are treatments used at the onset of a migraine attack to reduce the symptoms associated with migraine. There are a variety of medications available for the acute treatment of migraines, however the same treatment may not work for every patient. Finding the right medication depends on any other health conditions or medications, and the severity of your attacks (1).

Your doctor can also help you to manage lifestyle triggers and comorbidities. Addressing lifestyle factors is an important early step of treatment, and can ensure you are taking the medication best suited to the severity and frequency of your attacks (2).

This article covers some commonly recommended medications, including:

  • Aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs)
  • Paracetamol
  • Triptans
  • Anti-nausea drugs
  • Ergotamine compounds
  • Nerve stimulation devices
  • Opioids

First-line treatment

These acute medications are often a doctor’s first recommendation for migraine. First-line treatments generally provide the best results with the fewest side effects, targeting either the cause of the disease (i.e. neurological inflammation in migraine) or the majority of the symptoms.

NSAIDs and Paracetamol (simple analgesics)

Mild to moderate migraine attacks are generally treated with NSAIDs (aspirin, ibuprofen) or paracetamol. These medications are preferable because of their accessibility: they are over-the-counter, cheap, easy to take, and most people are already familiar with them. The dose of NSAID is often higher in migraine however (e.g. 900mg for aspirin or 600mg for ibuprofen), and you need to be careful of the total dose of each medication if using combination drugs with multiple active ingredients in one pill (2). Caffeine has been shown to work synergistically with some analgesics to provide more effective pain relief, however regular excess caffeine may also be a migraine trigger (3).

Triptans

Triptans are migraine-specific drugs that activate serotonin receptors, which blocks the release of inflammatory markers and markers involved in the dilation of blood vessels, in order to block the transmission of pain signals to the brain (4). They are recommended for patients with moderate to severe migraine attacks, or for those with milder attacks that don’t respond to generic painkillers. As a class, triptans reduce headache pain within two hours in 42-76% of patients, and relieve pain entirely in 18-50% (5). Triptans cause constriction of blood vessels, and so patients with cardiovascular disease should avoid them (2).

Most migraine patients will respond to at least one type of triptan medication, with trials suggesting that it is worth trying other types if the first one doesn’t work (4).For patients who have only a partial response to triptans, combination with NSAID therapy has been shown to be more effective than either medication alone (6). The table below provides an overview of the different types of triptan medications available in Australia.

Triptans available in Australia for migraine (2, 17)

Generic nameBrandsFormulationDosing (maximum dose)*
SumatriptanImigran™
Clustran™
Sumagran™
Sumatran™
and others
Tablet or fast disintegrating tablet50-100mg (300mg/day)
Nasal spray (10mg or 20mg)10-20mg one nostril (40mg/day)
Subcutaneous injection**6mg autoinjector (12mg/day)
RizatriptanMaxalt™
Rixalt™
and others
Tablet or wafer10mg (30mg/day)
EletriptanRelpax™Tablet 40mg40-80mg (160mg/day)
Tablet 80mg
ZolmitriptanZomig™
and others
Tablet2.5-5mg (10mg/day)
NaratriptanNaramig™Tablet2.5mg (5mg/day)
*Dosages apply to adults over 18. Take these medications only as directed by your doctor or pharmacist.
**Sumatriptan injection not subsidised on PBS

The Therapeutic Goods Administration (TGA) published a recommendation in February 2020 that sumatriptan and zolmitriptan should be available from pharmacists without a prescription (7). As of March 2021, sumatriptan has been made available as a ‘pharmacist only’ medication in a packet of two, and the remainder of triptans remain prescription only (8,9). 

One risk for both triptans and simple analgesics is medication overuse. Taking any class of painkiller too often can worsen migraine or other headache disorders by increasing the amount of inflammation in the brain and decreasing the brain’s ability to inhibit pain (10). It is important therefore to limit triptans to less than 10 days a month and simple analgesics to no more than 15 days a month. This is part of the reason that if you have more than four migraine days per month, management with your doctor will also focus on preventive medication and lifestyle changes.

Second-line treatment

If you cannot use, or have only a partial response, to triptans or simple analgesics, there are other acute medications available. These medications are considered second-line because they generally target fewer symptoms, are less effective, or are prone to causing side effects. However, patients’ medical histories and symptoms vary widely, and for some people these medications are used first line.

Anti-nausea drugs (antiemetics)

Nausea is one of the common symptoms that differentiates migraine from a tension-type headache. For some patients, oral analgesics are hard to use because the nausea is worsened by trying to swallow a tablet with fluids. In this case, nausea can be avoided by taking analgesics in a dissolvable wafer, as a spray, injection or suppository, or intravenously (2). 

If nausea is one of your primary symptoms however, antiemetics are recommended to treat migraine attacks.

Antiemetics available in Australia for migraine (11)

Generic nameFormulationAvailabilityDosing (maximum dose)*
MetoclopramideTablet (5 or 10mg)Prescription 10-15mg (40-60mg)
InjectionPrescription 10mg / 2ml (30mg / 6ml)
Combined tablet (5mg with 500mg paracetamol)Pharmacist only1-2 tablets (max 6 per day/ 30mg metoclopramide)
ProchlorperazineTablet (5mg)Pharmacist only, prescription for >10 tablets1-2 tablets (max 6 per day/ 30mg prochlorperazine)
Suppository (5 or 25mg)Prescription 25mg (50mg)
InjectionPrescription 12.5mg / 1ml (40mg)
DomperidoneTabletPrescription 10mg (40mg)
*Dosages apply to adults over 18. Take these medications only as directed by your doctor or pharmacist.

 

None of the above medications were developed specifically for migraine, except for those sold as a combined tablet with paracetamol. Metoclopramide and prochlorperazine are the antiemetics most commonly recommended for migraine, because they don’t cause major blood pressure changes, require cardiac monitoring, and may themselves also bring additional pain relief (12,13,16). 

There is also evidence to suggest that antiemetics can work synergistically with migraine treatments particularly in the setting of nausea or vomiting (15). One emergency department study showed that intravenous metoclopramide and prochlorperazine had a similar level of efficacy (12). Your doctor will be able to recommend which drug is more suitable based on your symptoms and reaction to previous medications.

Ergotamine compounds

Similar to triptans, ergotamine and dihydroergotamine (DHE) are migraine-specific drugs that target serotonin receptors (4). However, triptans have mostly replaced ergotamines, because they are more effective and ergotamines tend to cause side effects such as nausea. There are no ergotamine compounds currently available in Australia (11).

Nerve stimulation devices

While it is not a medication, nerve stimulation devices are an acute migraine treatment that have become available in recent years. These devices are held against or attached to your skin, and emit electrical pulses in order to stimulate nerves affected by migraine. 

Cefaly is one brand that targets the trigeminal nerve, while Electrocore targets the vagus nerve. Research has shown they can be quite effective, with one study finding that patients had a 57.1% reduction in pain intensity after one hour, and 20% of patients were pain-free (14). These devices are a good option for people who are unable to take pharmaceuticals due to side effects or lack of effectiveness.

Opioids

In most cases, opioids are no longer prescribed for migraine due to high risk of dependence or medication overuse headache, however, they can be sometimes used sparingly for patients with refractory migraine (an attack that fails to respond to any other treatment) (4). If your doctor prescribes an opioid medication for your migraine, they will advise you of how and when to take it. You can also refer to healthdirect’s information hub about opioid medication and pain for other resources.

Further resources

References

  1. WJ Becker, 2015, Acute Migraine Treatment in Adults. https://doi.org/10.1111/head.12550 
  2. B Jenkins, 2020, Migraine management. https://doi.org/10.18773/austprescr.2020.047 
  3. M Nowaczewska et al, 2020, The Ambiguous Role of Caffeine in Migraine Headache: From Trigger to Treatment. https://doi.org/10.3390/nu12082259 
  4. B Gilmore & M Michael, 2011, Treatment of Acute Migraine Headache. PMID: 21302868. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/21302868/ 
  5. C Cameron et al, 2015, Triptans in the Acute Treatment of Migraine: A Systematic Review and Network Meta‐Analysis. https://doi.org/10.1111/head.12601 
  6. S Law et al, 2016, Sumatriptan plus naproxen for the treatment of acute migraine attacks in adults. https://doi.org/10.1002/14651858.CD008541.pub3 
  7. Therapeutic Goods Administration, 2020, Interim decisions and invitation for further comment on substances referred to the November 2019 ACMS/ACCS meetings. Retrieved from: https://www.tga.gov.au/book-page/11-interim-decision-relation-sumatriptan 
  8. Therapeutic Goods Administration, 2021, ARTG ID 52261 [Sumatriptan public ARTG summary]. Retrieved from: https://tga-search.clients.funnelback.com/s/search.html?collection=tga-artg&profile=record&meta_i=52261 
  9. Therapeutic Goods Administration, 2021, ARTG ID 61326 [Zolmitriptan public ARTG summary]. Retrieved from: https://tga-search.clients.funnelback.com/s/search.html?collection=tga-artg&profile=record&meta_i=61326 
  10. I Meng et al, 2011, Pathophysiology of medication overuse headache: Insights and hypotheses from preclinical studies. https://doi.org/10.1177%2F0333102411402367 
  11. Therapeutic Goods Administration, 2021, ARTG Search [multiple searches & records]. Retrieved from: https://tga-search.clients.funnelback.com/s/search.html?query=&collection=tga-artg 
  12. BW Friedman, 2008, A Randomized Controlled Trial of Prochlorperazine Versus Metoclopramide for Treatment of Acute Migraine. https://doi.org/10.1016/j.annemergmed.2007.09.027 
  13. BW Friedman, 2020, A Randomized, Double‐Dummy, Emergency Department‐Based Study of Greater Occipital Nerve Block With Bupivacaine vs Intravenous Metoclopramide for Treatment of Migraine. https://doi.org/10.1111/head.13961 
  14. DE Chou et al, 2017, External Trigeminal Nerve Stimulation for the Acute Treatment of Migraine: Open-Label Trial on Safety and Efficacy. https://doi.org/10.1111/ner.12623  
  15. S Derry & RA Moore, 2013, Paracetamol (acetaminophen) with or without an antiemetic for acute migraine headaches in adults. https://doi.org/10.1002/14651858.CD008040.pub3 
  16. A Derbent, 2005, Can antiemetics really relieve pain?. https://doi.org/10.1007/BF02850080 
  17. Healthdirect, 2021, Medication search [multiple searches & records]. Retrieved from: https://www.healthdirect.gov.au/medicines 
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