Medicines to Treat Migraine Attacks

What is migraine?

Migraine is a condition that causes episodes ('attacks') of headaches, and often other symptoms such as vomiting. Between migraine attacks, the symptoms go completely. A separate leaflet called 'Migraine' gives general details about migraine.

This leaflet is about medicines which can be used to treat each attack of migraine. (If you have frequent or severe attacks of migraine, another option is to take a medicine to prevent migraines. See separate leaflet called 'Medicines to Prevent Migraine Attacks' for more details.)

There are four types of medicines that are commonly used to treat migraine attacks: ordinary painkillers, anti-inflammatory painkillers, anti-sickness medicines, and triptans. These are discussed below.

Painkillers

Paracetamol or aspirin work well for many migraine attacks. (Children under 16 should not take aspirin.) Take a dose as early as possible after symptoms begin. If you take painkillers early enough, they often reduce the severity of the headache, or stop it completely. A lot of people do not take a painkiller until a headache becomes really bad. This is often too late for the painkiller to work well. The only solution may then be to find a a quiet, dark room to 'sleep it off'.

Take the full dose of painkiller. For an adult this means 900 mg aspirin (usually three tablets) or 1000 mg of paracetamol (usually two 500 mg tablets). Repeat the dose in four hours if necessary. Soluble tablets are probably best as they are absorbed more quickly than solid tablets.

It is best not to use codeine and medicines containing codeine such as co-codamol to treat migraine. This is because codeine can make nausea (feeling sick) and vomiting worse, which can make migraine worse. They are also more likely than paracetamol or aspirin to cause 'medication headache' if you use them frequently. (See leaflet called 'Medication Headache' for details.)

Anti-inflammatory painkillers

Anti-inflammatory painkillers probably work better than paracetamol or aspirin to ease migraine. (Although, strictly speaking aspirin is an anti-inflammatory painkiller.) They include ibuprofen which you can buy at pharmacies or get on prescription. Other types such as diclofenac, naproxen, or tolfenamic acid need a prescription. Some points about anti-inflammatory medicines include:

• It may be best to take the maximum allowed dose as soon as the headache begins rather than taking smaller doses.
• One brand of Ibuprofen 'dissolves' and disperses in the mouth, and is swallowed with saliva. This may be easier to take than tablets if you feel sick.
• One brand of diclofenac comes as a suppository. This may be useful if you usually vomit with a migraine.
• In general, pregnant women should not take anti-inflammatory medicines.
• Some people with asthma, high blood pressure, kidney failure, or heart failure may not be able to take anti-inflammatory painkillers.
• For a full list of cautions and possible side-effects for your particular medicine, see the leaflet that comes in the medicine packet.

Dealing with nausea and vomiting

Migraine attacks may cause nausea (feeling sick) or vomiting. The nausea causes poor absorption of tablets into your body. If you take painkillers, they may remain in your stomach and not work well if you feel sick. You may even vomit the tablets back. Tips that may help include:

• Use soluble (dissolvable) painkillers. These are absorbed more quickly from your stomach and are likely to work better.
• You can take an anti-sickness medicine in addition to painkillers. A doctor may prescribe one. For example, domperidone or metoclopramide. (But note: due to possible side-effects, metoclopramide should not be used by pregnant or breastfeeding women, children, and young adults.)
• Like painkillers, anti-sickness medicines work best if you take them as soon as possible after symptoms begin.
• An anti-sickness medicine (domperidone) is available as a suppository if you feel very sick or vomit during migraine attacks.

Combinations of medicines
Some brands of tablets contain both a painkiller and an anti-sickness medicine. For example, Migraleve, Paramax, Migramax, and Domperamol. They may be convenient. However, the dose of each constituent may not suit everyone, or be strong enough. You may prefer to take painkillers and anti-sickness medicines separately so that you can control the dose of each, and you know exactly what you are taking.

Triptan medicines

A triptan is an alternative if painkillers or anti-inflammatory painkillers do not help much. Triptan medicines include: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan. They each have different brand names too. Triptans are not painkillers. They work by interfering with a brain chemical called 5HT. An alteration in this chemical is thought to be involved in causing migraine.

Do not take a triptan too early in an attack of migraine. (This is unlike painkillers described above which should be taken as early as possible). You should take the first dose when the headache (pain) is just beginning to develop, but not before this stage. (That is, do not take it in the aura stage if you have an aura. Studies have shown that they do not work as well if taken too early.)

If the first dose of the triptan does not work, do not take a further dose as it is not likely to work either. (The exception to this is zolmitriptan, where a second dose can be tried even if the first does not work.)

If a low dose does not work so well, your doctor may prescribe a larger dose. Also, some triptans work in some people and not in others. Therefore, if one triptan does not work, a different one may well do so. In some cases, some people have tried three or more different triptans before finding one that works best for them. However, do not make a judgement until you have tried a particular triptan for 2-3 migraines. Even in people where triptans are effective, a triptan does not work for every migraine. The aim is to find the one that works most of the time for you. See your doctor to discuss trying another if the first one does not seem to help much.

Read the packet leaflet for possible side-effects. If side-effects occur they are usually mild and do not usually last long. The most common include a warm-hot sensation, tightness, tingling, flushing, and feelings of heaviness or pressure in areas such as the face, arms, legs and occasionally the chest. Some people feel a little unsteady or dizzy, develop a dry mouth, or feel sick. Sumatriptan can cause drowsiness. If this occurs do not do skilled tasks such as driving.

The way side-effects affect different people can vary between the different triptans. So, if one causes unpleasant side-effects, a switch to a different one may be fine.

Migraine itself can often cause nausea and vomiting. This can cause problems in taking triptan tablets. Options to consider if this is a problem include:

• Sumatriptan is also available as an injection.
• Rizatriptan and zolmitriptan are available as a wafer or tablet that disperses in the mouth, and is then swallowed with saliva.
• Zolmitriptan and sumatriptan are available as a nasal spray.
• To also take an anti-sickness medicine such as domperidone or metoclopramide (see above).

Most people who have migraine can usually find a triptan that works well for most migraines, and where side-effects do not occur or are not too bad. A main problem with triptans is that in about 1 in 4 cases, after taking a triptan which clears a headache, the headache returns within the next 48 hours. If this problem tends to happen with you, then options to consider are:

• You can take a repeat dose when the headache returns (if the first dose worked). A dose of triptan can be repeated within 2-4 hours (depending on the type). A maximum of two doses of almotriptan, eletriptan, naratriptan, and rizatriptan can be taken in 24 hours. Three doses (maximum 300 mg) of sumatriptan can be taken in 24 hours. Four doses of zolmitriptan (maximum 10 mg) can be taken in 24 hours. However, if you take frequent doses of a triptan there is a danger that you may get 'rebound' headaches called 'medication headache'. See separate leaflet called 'Medication Headache' for details.
• Your doctor may consider prescribing naratriptan or eletriptan. Return of the headache is thought to be less common after treatment with these triptans.
• Some people take a short course of an anti-inflammatory painkiller such as diclofenac or tolfenamic acid in the 24-48 hrs after the headache goes. This may prevent a return of the headache and reduce the need for a repeat dose of a triptan.

Some people cannot take triptans. For example, some people with heart disease, stroke disease, or peripheral vascular disease. Also, people at an increased risk of developing these conditions. Your doctor will advise.

Further sources of help and information

Migraine Action
Unit 6 Oakley Hay Lodge Business Park, Great Folds Road, Great Oakley, Northants, NN18 9AS
Tel: 01536 461333   Web: www.migraine.org.uk

Migraine Trust
2nd Floor, 55-56 Russell Square, London, WC1B 4HP
Tel: 020 7436 1336   Web: www.migrainetrust.org

© EMIS and PIP 2005   Updated: February 2005   Review Date: July 2006   CHIQ Accredited   PRODIGY Validated