Migraine headaches cause significant disability. An ideal acute migraine treatment would be an cheap, easy to tolerate oral medication that takes away the headache and restores the patient to normal function.
There are several migraine treatment options. They include:
Before the 1990's the prescription medications available for migraines were either not very effective or were narcotics, which are potentially addicting and cause drowsiness. Since the 1990’s a new class of medication, called triptans, has been used with much success. The triptans are available in multiple forms including tablets, nasal spray, and subcutaneous injection. All are extremely safe. Triptans provide more than just pain relief, but they are also effective in the total treatment of migraine symptoms including nausea, light and noise sensitivity, as well as sinus symptoms and neck pain.
WARNING: Patients with ischemic heart disease should not take triptan medications.
Imitrex® (sumatriptan) was the first triptan brought to market. Imitrex is available as an injection, nasal spray, and tablet. The injection is the fastest migraine reliever on the market, but has the highest incidence of side effects, which can be annoying but do not last long. It has a relatively high price, although the sumatriptan injection is now available in generic form which is still much more expensive than trade name oral medications. The tablet is the most convenient, easiest, and commonly used form of Imitrex and is generically available. An alternative to both the injection and tablet is the Imitrex nasal spray, which sometimes works faster than the tablet. The nasal spray is convenient for those patients that have early vomiting with their migraines. It is cheaper and less painful than the migraine injections. Sumavel® and Alsuma® represent easier to utilize injection devices that deliver SQ sumatriptan.
The combination of Imitrex with an NSAID (nonsteroidal anti-inflammatory drug) is called Treximet® and is now available. This combination works better than either by itself. Although not proven to work better than taking sumatriptan and 2 aleve separately, a number of patients believe the Treximet® is more effective.
The only other triptan offered in multiple forms is Zomig® (zolmitriptan) which comes in a tablet, dissolving tablet and nasal spray. The tablet and dissolving tablet are of equal effectiveness with nearly identical times of onset for headache relief. The nasal spray has an onset that is significantly faster than either tablet, but not as fast as the Imitrex injection. The nasal spray may be effective in patients who do not respond to the tablets.
The other triptans on the market, Amerge®, Axert®, Frova®, Maxalt® and Relpax®, are only available in tablet form. Maxalt® comes in a dissolvable tablet. (It is important to note that the dissolvable form is not absorbed more quickly into the bloodstream than the oral tablet.)
The oral tablets are divided into two groups, the fast acting and slower acting. The faster acting group includes Axert®, Imitrex®, Maxalt®, Relpax® and Zomig®. The slower acting group includes Amerge® and Frova®.
WARNING: Patients with ischemic heart disease should not take DHE containing medications.
When triptans are ineffective, formulations of DHE is commonly used. DHE-45 is a form of DHE that can be injected either directly into the muscle or under the skin. Migranal® is a form which can be used nasally. It is much more expensive than any of the other acute treatments on this page. Levadex® is an inhaled formulation of DHE. At this time it is not yet on the market. Data indicates it will work very quickly. There is a large body of data that DHE products work even when migraines have been present for several hours. It is common for triptans to not work well once the patient develops allodynia. Allodynia is when a sensory input that should not cause pain causes pain. A common example of this is brushing the hair causing pain during a migraine.
Aspirin based products can be very useful for some migraine patients. Because caffeine can cause rebound headaches, regular aspirin or migralex (aspirin combined with magnesium) should be used if it works well.
Cambia® represents the only non-steroidal anti-inflammatory medication (NSAID) to be FDA approved for migraine. While it is common to use over the counter antiinflammatory medications to treat migraines, in most patients this only works when the headaches are mild. Cambia®, in contrast, has been demonstrated to work even when the headaches are severe.
Narcotics and butalbital products should, in general, be avoided. They have a propensity to cause rebound. They generally do not return the patient to normal function.
This educational content was written by Brian D. Loftus, MD, a neurologist, headache specialist and developer of iHeadache. The science and study of headaces is changing rapidly. If there is information on this page that is incorrect or needs revision, please contact us.
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