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. See separate leaflet called 'Migraine' which 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 'Migraine - 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, antisickness medicines, and triptans. These are discussed below.

Painkillers

Paracetamol or aspirin work well for many migraine attacks. 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 quiet, dark room to 'sleep it off'.

Take the full dose of painkiller. For an adult this means 900 mg aspirin (usually three 300 mg 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 separate leaflet called 'Headache - Medication Induced' for details.)

Note: aspirin has fallen from favour for the treatment of many painful conditions. However, for adults with migraine, it often works very well and is well worth a try. For example, there is some evidence from research that aspirin can be as effective as sumatriptan (a triptan - see below) for migraine attacks.

Anti-inflammatory painkillers

Anti-inflammatory painkillers probably work better than paracetamol to ease migraine. 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. Also, strictly speaking, aspirin is an anti-inflammatory painkiller. Some points about anti-inflammatories include:

• It may be best to take the maximum allowed dose as soon as the headache begins rather than taking smaller doses.
• Ideally, take an anti-inflammatory medicine with some food or milk. This helps to reduce the risk of developing a stomach upset which some people have with these medicines. However, this may not be possible if you feel sick or vomit.
• One brand of ibuprofen 'dissolves' and disperses in the mouth, and is swallowed with saliva. This may be easier to take than other tablets if you feel sick.
• One brand of diclofenac comes as a suppository. This may be useful if you usually vomit with a migraine attack.
• 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.
• As mentioned, one brand of diclofenac comes as a suppository. This may be useful if you usually vomit with a migraine.
• You can take an antisickness medicine in addition to painkillers. A doctor may prescribe one. For example, domperidone, prochlorperazine or metoclopramide.
• Like painkillers, antisickness medicines work best if you take them as soon as possible after symptoms begin.
• An antisickness medicine, domperidone, is available as a suppository if you feel very sick or vomit during migraine attacks.
• Prochlorperazine comes in a 'buccal' form which dissolves between the gum and cheek. This can be useful if you feel sick and do not wish to swallow a tablet.

Combinations of medicines

Some brands of tablets contain both a painkiller and an antisickness 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 antisickness 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. You need a prescription for most triptans, but you can buy sumatriptan from pharmacies.

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, the same one at a higher dose, or 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 migraine attacks. Even in people where triptans work well, a triptan does not work for every migraine attack. The aim is to find the one that works most of the time for you. See your doctor to discuss trying a higher dose, or a different one, if the first one does not seem to help much.

Read the leaflet in the packet 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.

A migraine attack 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.
• Also take an antisickness medicine such as domperidone or metoclopramide (see above).

Most people who have migraine can usually find a triptan that works well for most migraine attacks, 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). But, make sure you do not exceed the maximum dose recommended over a 24 hour period. For example, total dosage of sumatriptan per 24 hours should not exceed 300 mg orally (tablets) or 40 mg intranasally (nasal spray). Also, note: 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 'Headache - Medication Induced' 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. Also, pregnant women and children should not take triptans.

See separate leaflet called 'Triptans' for more details.

More on combination treatments

If none of the above treatments are useful, there is some evidence to suggest that the combination of sumatriptan (a triptan) plus naproxen (an anti-inflammatory painkiller) works better than either medicine alone. However, it is best to talk it through with your doctor before embarking on these sort of combinations.

A note of caution - medication induced headache

Medication induced headache is caused by taking painkillers or triptans too often for tension-type headaches or migraine attacks. It is sometimes called medication overuse headache. It is a common cause of headaches that occur daily, or on most days. About 1 in 50 people develop this problem at some time in their life. If you find that you are getting headaches on most days then this may be a cause. See a doctor for advice. See separate leaflet called 'Headache - Medication Induced' for more details.

Medicines for migraine attacks in children

Many of the medicines used by adults for migraine are not licensed for children. Paracetamol or ibuprofen are suitable and are commonly used. Apart from these you must check with your doctor or pharmacist before giving a child any other medicine for migraine. For example, triptans are not licensed for children and only some antisickness medicines can be used.

Medicines for migraine attacks when pregnant or breastfeeding

The good news is that about 2 in 3 women with migraine have an improvement whilst pregnant or breastfeeding. However, about 1 in 20 women with migraine find that their migraine gets worse whilst pregnant.

The bad news is that most of the medicines used to treat migraine (and sickness) should not be taken if you are pregnant or breastfeeding. Paracetamol is the medicine most commonly used as it is known to be safe during pregnancy. If you are pregnant or breastfeeding you should always check the leaflet that comes with the medicine to see if it is suitable. Check with your pharmacist or doctor if you are not sure.

In summary

From the above information you can see that there are several options to try when you have a migraine attack. Many people under-treat their migraine attacks or do not realise that if one treatment does not work then it is normal to try a different treatment for the next migraine attack. You can discuss the options with your doctor.

In short, it is normal and common to try different treatment options for migraine over a period of time. The purpose is to be certain that you have found what treatment or treatment combination suits you best.

As a general 'rule of thumb', it is best to use the same treatment for three migraine attacks to assess how well it works. This is because even if one treatment normally works for you, there will be times when it may not work so well. You may even wish to keep a diary for a while. For example, write down an account of each migraine attack, symptoms and severity. Also, record exactly what treatment you used for that attack, and the dose. And, when the attack is over, make a note as to how well the treatment had worked, and how quickly, and whether you had any side effects. In this way you will be able to be objective and find which is the best treatment for you. See separate leaflet called 'Migraine - Triggers and Diary' which includes a migraine diary that you may like to print out and use.

Further sources of help and information

Migraine Action

27 East Street, Leicester, LE1 6NB
Tel: 0116 275 8317 Web: www.migraine.org.uk

Migraine Trust

2nd Floor, 55-56 Russell Square, London, WC1B 4HP
Tel: 020 7462 6601 Web: www.migrainetrust.org