Migraine drugs are generally categorized as acute treatments and preventive treatments. Acute treatments are taken at the first sign of a migraine attack to reduce pain and other symptoms. Some drugs for acute migraine treatment can be taken only once per day, while others can be taken more than once per day if additional symptom relief is needed. Many preventive migraine treatments are pills that are taken daily, although the newer CGRP antibodies are injected once a month or infused intravenously once every three months. Botox injections, another preventive migraine treatment, are generally given every 12 weeks. While the development of new drugs is good news, it’s important to note that new drugs tend to be expensive, meaning they are out of reach for some of the people who could benefit from them. They also don’t work for everyone. Neuromodulation is another option for migraine treatment that has been shown to reduce migraine days or alleviate the symptoms of a migraine attack in some people. A variety of neuromodulation, or neurostimulation, devices can deliver electric or magnetic pulses to specific nerves involved in migraine, calming overexcitable nerves and changing the way pain messages are relayed to the brain. Certain mind-body therapies, such as acupuncture, biofeedback, and massage, can also help to prevent migraine attacks in some people. And avoiding known triggers as best as possible may help to reduce the number of migraine attacks a person has.
New Drug Classes
Some of the anti-CGRP drugs prevent CGRP from binding to receptors in various cell types in the brain, and some bind to the peptide itself, inactivating it.
CGRP (Calcitonin Gene-Related Peptide) Antibodies The CGRP antibodies, which include Vyepti (eptinezumab), Aimovig (erenumab), Ajovy (fremanezumab), and Emgality (galcanezumab), are approved for preventive treatment of migraine. They’ve been shown to reduce the number of migraine days compared to placebo in both episodic and chronic migraine.
Episodic migraine is defined as fewer than 15 migraine days per month, while chronic migraine is defined as 15 or more migraine days per month. 5-HT1F Receptor Agonist Reyvow (lasmiditan), the only drug in this class approved thus far, is approved for acute migraine treatment. For some people with migraine, over-the-counter pain relievers are sufficient to treat migraine attacks, but for many others, prescription drugs are needed for adequate relief. In general, to avoid drug side effects and the possible consequences of overuse, you should take pain-relieving drugs only when you first experience signs or symptoms of migraine.
Imitrex (sumatriptan)Axert (almotriptan)Relpax (eletriptan)Maxalt (rizatriptan)Zomig (zolmitriptan)
Longer-acting oral triptans include:
Frova (frovatriptan)Amerge (naratriptan)
Triptans that come in a nasal spray include:
Imitrex (sumatriptan)Zomig (zolmitriptan)
And one triptan, Imitrex, is available as a self-administered, subcutaneous injection. Common side effects of triptans include nausea, dizziness, drowsiness, and muscle weakness. Because one of their actions is to constrict blood vessels, triptans aren’t recommended for people at high risk for a stroke or heart attack.
Ergots
Two combinations of ergotamine and caffeine are still available in the United States: Cafergot, which is taken as a tablet, and Migergot, which is a rectal suppository. However, these drugs are less effective than triptans at stopping a migraine attack, and they commonly cause nausea and vomiting as a side effect. They are seldom used in North America today but continue to be used more widely in other parts of the world. Similar to triptans, ergotamines are not recommended for people at high risk for a stroke or heart attack. Dihydroergotamine is also available as a self-injection and as a nasal spray, Migranal, neither of which are as effective as the drug given intravenously. A new DHE delivery device approved in September 2021 and marketed as Trudhesa delivers the drug to the upper nasal cavity, which is rich in blood vessels. The expected benefit of Trudhesa over older delivery methods is faster drug uptake and faster migraine relief.
CGRP Receptor Antagonists
In 2019, the U.S. Food and Drug Administration (FDA) approved Ubrelvy (ubrogepant), an oral CGRP receptor antagonist — also known as a CGRP blocker, or inhibitor — that’s used to treat symptoms in adults once a migraine attack has already started. Ubrelvy can be used to treat migraines with aura or without aura. Side effects of Ubrelvy include nausea, dizziness, drowsiness, and dry mouth. The most common side effects of Nurtec ODT is nausea.
Unlike triptans, CGRP receptor antagonists are believed to be safe for people with vascular disease that raises their risk of heart attack or stroke.
Glucocorticoids, or Steroids
Opioids
Nausea Medication
If your migraine attacks include nausea and vomiting, your doctor may prescribe an oral anti-nausea drug, also known as an antiemetic, to take along with a pain-relieving medication. Antiemetics used for migraine relief include:
ChlorpromazineCompro (prochlorperazine)Reglan (metoclopramide)
Reglan increases muscle contractions in the upper digestive tract to speed the rate at which food in the stomach is moved to the small intestine. Chlorpromazine and Compro, in contrast, do reduce nausea but don’t affect the rate of stomach emptying.
Nerve Blocks for Acute Migraine Pain Relief
Emergency Treatment of Intractable Migraine
DihydroergotamineAntiepilepticsAntihistaminesAnti-inflammatoriesSteroidsMuscle relaxantsAntiemetics (antinausea drugs)
To be sure you get the treatment you need when seeking emergency care, consider asking the doctor who treats your migraine to write down an emergency migraine treatment plan for you that you can bring with you to the hospital or urgent care center.
You have four or more migraine attacks per month.Your migraine attacks last longer than 12 hours.Pain-relieving medication is ineffective.You regularly experience prolonged auras or numbness and weakness.Your migraine attacks are disabling or adversely affect other medical conditions you have.
In general, your doctor may recommend that you take preventive medication daily or only when a predictable migraine trigger (such as menstruation) is approaching. Many of the drugs that have been used in preventive therapy have not been specifically studied in clinical trials to target migraine. But that has recently been changing. If taking a preventive medicine succeeds in stopping your migraine attacks, your doctor may recommend tapering off the medication to see if your attacks return without it.
CGRP Receptor Antagonists for Prevention
The first two CGRP receptor antagonists to come on the market in the United States, Nurtec and Ubrelvy, were initially approved for acute treatment of migraine. However, Nurtec ODT was subsequently approved to also be used as a preventive treatment for episodic migraine. A third oral CGRP receptor antagonist, Qulipta (atogepant), received FDA approval in September 2021 only as a preventive medication for episodic migraine. The drug is taken once daily and is available in three strengths: 10 mg, 30 mg, and 60 mg. Common side effects of Qulipta include constipation, nausea, and fatigue.
CGRP Antibodies
Aimovig (erenumab) is self-injected monthly, according to the FDA.Emgality (galcanezumab-gnlm) is injected monthly.Ajovy (fremanezumab-vfrm) can be injected either monthly or every three months.Vyepti (eptinezumab) is administered intravenously (IV) every three months.
The most common side effects of CGRP antibodies are injection-site reactions and constipation.
Antihypertensive Drugs
Several classes of blood-pressure-lowering drugs are used to prevent migraine. Examples of beta-blockers used to treat migraines include:
Inderal LA or Innopran XL (propranolol)Lopressor (metoprolol tartrate)Betimol (timolol)
It may take several weeks after starting these drugs to notice any improvement. Calcium Channel Blockers Calcium channel blockers are more often used to treat high blood pressure, but may be helpful in preventing migraine attacks. One common example is Calan or Verelan (verapamil). Angiotensin-Converting Enzyme (ACE) Inhibitors These drugs are more commonly used to treat high blood pressure and congestive heart failure.
Antidepressants
Certain antidepressants may help prevent some types of headaches, including migraine attacks. You don’t need to have depression to benefit from these drugs. Tricyclic antidepressants can cause dry mouth, constipation, weight gain, and other side effects.
Antiseizure Drugs
Certain anti-seizure, or anti-epileptic, drugs, including Depacon or Depakote (valproate sodium) and Topamax (topiramate), have been shown to reduce the frequency of migraine attacks. These drugs have significant side effects — including nausea, tremor, weight gain or loss, hair loss, dizziness, diarrhea, and concentration problems. They should not be used if you’re pregnant or plan to become pregnant.
Botox for Chronic Migraine Prevention
Botox injections can cause neck pain and headache as temporary side effects. Several nerve stimulation devices are already on the market for migraine, and others are in development. Cefaly The Cefaly Dual is an external trigeminal nerve stimulator that sends electrical impulses through a self-adhesive electrode placed on the forehead to stimulate the trigeminal nerve, reducing the frequency and intensity of migraine attacks. As of October 2020, it no longer requires a prescription to purchase and is also not covered by insurance. Nerivio Nerivio is a remote neuromodulation armband device for the acute treatment of migraine with or without aura in people age 12 and older, as of January 2021. The device is available only with a doctor’s prescription and is controlled by an app designed to provide personalized treatments. GammaCore The gammaCore Sapphire is a handheld device that delivers small electrical pulses to the vagus nerve on either side of the neck. The rechargeable and device requires a doctor’s prescription and is designed for multiyear use. Relivion The Relivion is a noninvasive headset device that delivers pulses of electrical current to stimulate the occipital and trigeminal nerves. For now, it’s only available in Europe. STMS Mini The eNeura sTMS mini delivers a magnetic pulse to the back of the head that’s intended to interrupt abnormal electrical activity in the brain associated with migraine attacks. Because the primary U.S. manufacturer of sTMS technology, eNeura, declared Chapter 7 bankruptcy in 2020, it’s unclear whether the device will remain on the market, at least in the United States. Learn More About Nerve Stimulation Devices for Migraine Treatment
Applying hot or cold compresses to your head and neck may help, notes the Mayo Clinic.Taking a warm shower or bath can have a similar effect to hot compresses.Resting in a dark, quiet room can also help if you feel a migraine attack coming on.Meditating or doing yoga may help to reduce symptoms and can also help to prevent attacks when done regularly.
Home Nausea Remedies
Avoiding Common Triggers
You can also do a variety of things to avoid common migraine triggers and possibly reduce the frequency of attacks. These include:
Eating Meals on a Regular Schedule Skipping meals or going for too long between meals is a common migraine trigger, notes Migraine Again.Getting Enough Sleep Getting an adequate amount of sleep each night is important, but oversleeping can be counterproductive and contribute to migraine attacks. Migraine experts recommend that you go to bed and wake up on a regular schedule.Managing Stress Feeling highly stressed is often identified as a migraine trigger, although sometimes the attack starts after the high stress level has passed, according to Migraine Again.Regularly practicing a relaxation technique or using a mind-body therapy may help you to manage life stresses.Keeping a Headache Diary Keeping a headache diary can help you and your doctor learn more about what triggers your migraine attacks, as well as what treatments are most effective.
The first step toward trying any of these mind-body therapies is finding a trained practitioner. Speak to the doctor who treats your migraine about the availability of such specialists in your area. In some cases, online or telemedicine versions of a therapy may be available.
Additional reporting by Brian P. Dunleavy.
