Discussing migraine medications can get confusing, partly because there are so many, partly because they’re used for different purposes. Migraine medications fall into three categories – preventive medications, abortive medications, and rescue medications.
Preventive medications are taken daily to reduce the frequency and severity of migraine attacks. Most doctors recommend preventive medications if you average three migraines a month or more, or if your migraines are especially debilitating. Some people are naturally reluctant to start taking a daily medication that may need to be taken indefinitely. Here’s where we need to stop and think a bit. Migraine is a genetic neurological disease, not just having bad headaches. Most people aren’t so reluctant to take daily medications for diseases such as diabetes or thyroid disease. Once we get our heads around the fact that migraine is a disease, resistance to taking daily medications seems to lessen.
There are only four medications that have been officially approved by the FDA for migraine prevention:
- Inderal (propranolol), a beta blocker originally developed for heart disease and high blood pressure
- Blocadren (timolol), another beta blocker
- Depakote and Depakote ER (divalproex sodium), a neuronal stabilizing agent, also known as an anticonvulsant, originally developed for seizure disorders
- [Topamax](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/SK7QKL5H/topamax-oral-14494%5B1%5D) (topiramate), another neuronal stabilizing agent
In addition to those approved for migraine prevention, the FDA has also approved onabotulinumtoxinA (Botox) for the treatment (prevention) of chronic migraine.
There are many other medications (more than 100 total) that are being used effectively for migraine prevention. It’s quite common for medications to be prescribed for conditions other than those for which they were first developed. This is called off-label prescribing. Medications prescribed off-label for migraine prevention include:
- Antihypertensives (blood pressure medications)
- Alpha-2 Agonists such as clonidine (Catapres)
- ACE Inhibitors such as Lotensin and Monopril
- Beta Blockers such as Lopressor and Corgard
- Calcium Channel blockers such verapamil, Cardizem, and Plendil
- Antihistamines such as cyproheptadine (Periactin)
- Tricyclic antidepressants such as amitriptyline
- SSRI antidepressants such as Lexapro
- SNRI antidepressants such as Effexor
- MAOI antidepressants such as Nardil
- Cox-2 Enzyme Inhibitors such as Celebrex
- Muscle relaxants such as Soma and Zanaflex
- Neuronal stabilizing agents (anticonvulsants) such as Keppra and Zonegran
- Leukotriene Blockers such as Singulair and Accolate
- Medications generally used for ADD such as Adderall and Strattera
- Medications developed for dementia or Alzheimer’s disease such as Namenda
- Dietary supplements such as Coenzyme Q10, vitamin B2 and magnesium
Abortive medications actually work to stop the Migrainous process itself, thus stopping the associated symptoms as well. Migraineurs may still experience the migraine postdrome, that phase that some people call a “migraine hang-over.” Migraine abortives include:
- Triptans:[Imitrex](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/2YTNOCGF/imitrex-oral-11571%5B1%5D) (sumatriptan), [Maxalt](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/IQUOVZ8L/maxalt-oral-8440%5B1%5D) (rizatriptan), [Zomig](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/SK7QKL5H/zomig-oral-5400%5B1%5D) (zolmitriptan), [Amerge](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/J5ZNVEBI/amerge-oral-6423%5B1%5D) (naratriptan), [Relpax](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/YMDUKRPA/relpax-oral-64734%5B1%5D) (eletriptan), [Axert](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/QSGGW9F5/axert-oral-21400%5B1%5D) (almotriptan), and [Frova](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/MZF31NSF/frova-oral-22253%5B1%5D) (frovatriptan) – as well as Treximet, which is a combination of Imitrex and naproxen sodium.
- Ergotamines such as [Migranal nasal spray](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/2YTNOCGF/migranal-nasl-5527%5B1%5D) and DHE-45 (injectable)
- Isometheptene compounds such as [Midrin](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/MZF31NSF/medication-midrin-equivalents%5B1%5D). Midrin and all but one Midrin equivalent medications have been pulled from the market. It’s uncertain if any will remain, but an equivalent medication can be made by a compounding pharmacy.
In a few cases, triptans are used for migraine prevention. Amerge and Frova have been studied and proven effective for the prevention of menstrually triggered migraines when taken twice a day for five to seven days beginning two days before the onset of the menstrual period.
On April 15, 2008, a new variation on a triptan was introduced, Treximet. Treximet combines sumatriptan (Imitrex) and naproxen sodium, an NSAID. The purpose for this combination is for the sumatriptan to target the nerves and blood vessels involved in a migraine while the naproxen sodium targets inflammation. In 2015, Treximet was approved by the FDA for use by adolescents.
Rescue medications are those taken if abortives fail or if you can’t take the abortive medications. Most rescue medications are pain medications. Other types of medications are also used to help get through a migraine by reducing nausea and helping migraineurs relax. They don’t have the ability to abort a migraine, but will hopefully mask the pain for a few hours while the migraine runs its course. Medications used for rescue include:
- Butalbital compounds: Fiorinal, Fioricet, etc. (with or without codeine)
- Acetaminophen with codeine, oxycodone, or hydrocodone such as Vicodin, Percocet, Tylenol #3
- Other analgesics (pain relievers) such as Ultram, ketorolac (Toradol), and others
- In some cases, doctors will prescribe injectable medications such as Demerol to be used at home in emergencies.
- Antinausea medications such as Compazine, Phenergan, Reglan, Zofran
- Muscle relaxants such as Soma, Skelaxin, Zanaflex
Wrapping It Up
Which medications are part of your regimen depends upon you and your migraines. Migraineurs with infrequent mild to moderate migraine may do fine with abortive medications only. There are also some in that situation who can even manage with a mild pain reliever. For those whose migraines are frequent, the most effective regimen will include preventives to reduce the frequency and severity of migraines, abortives to stop migraines as they occur, and rescue medications to help avoid trips to the emergency room if abortives fail. Some migraineurs, particularly those with a history of cardiovascular disease, may not be able to use abortives and will need to limit their regimens to preventive and rescue medications.
More Helpful Information:
- Migraine and Headache Prevention - So Many Options
- Medication Overuse Headache - When the Remedy Backfires
- Migraine Rescue Treatments - Vital to Our Treatment Regimens
_Reviewed by David Watson, MD. _
Teri Robert is a leading patient educator and advocate and the author of Living Well with Migraine Disease and Headaches. A co-founder of the Alliance for Headache Disorders Advocacy and the American Headache and Migraine Association, she received the National Headache Foundation’s Patient Partners Award and a Distinguished Service Award from the American Headache Society. Teri can be found on her website, and blog, Facebook, Twitter, StumbleUpon, Pinterest, LinkedIn, and Google+.