Migra Well

Migraine Treatments

Migraine treatment involves a multifaceted approach that includes acute and preventive medications, as well as lifestyle modifications. Treatment options range from triptans and NSAIDs for immediate relief to beta-blockers and CGRP inhibitors for prevention. Lifestyle changes, such as stress management, regular exercise, and dietary adjustments, play a crucial role in reducing migraine frequency and severity. This comprehensive approach aims to improve overall quality of life for those suffering from migraines.

Acute Abortive Medications

Wooden blocks with words NSAID and a stethoscope on table

NSAIDs and Analgesics

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and aspirin, play a pivotal role in migraine management. Effective in about 50% of cases, they are particularly beneficial for treating mild to moderate migraines. These medications help reduce inflammation and pain, offering a convenient and accessible first-line treatment option.

Bottle with words sumatriptan


Triptans are considered the first-line treatment for moderate to severe migraines. They work by stimulating serotonin receptors, which leads to vasoconstriction and inhibition of inflammation. Sumatriptan was the first triptan developed, followed by others like rizatriptan, zolmitriptan, and eletriptan, each with varying onset of action and duration. Generally, triptans are effective in about 70-80% of migraine attacks. See the latest advancements in triptans below.

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Used for nausea associated with migraines, anti-emetics like metoclopramide also enhance the absorption of other migraine medications. Besides controlling nausea, they indirectly improve the overall effectiveness of migraine management. Newer anti-emetics focus on minimizing side effects like sedation.

Chronic Prophylaxis Medications

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Beta-Blockers such as Propranolol initially developed for other conditions like hypertension and epilepsy, have been found effective in migraine prophylaxis. They generally reduce migraine frequency by 40-60%.
antidepressant word in a dictionary. antidepressant concept.

Antidepressants & Anticonvulsants

Amitriptyline can reduce migraine frequency by up to 60%. Topiramate shows a 50% reduction in migraine frequency in about 48% of patients.

capsules of medicine on white background

Calcium Channel Blockers

Calcium Channel Blockers, particularly Verapamil, play a significant role in migraine treatment for certain individuals. They are especially effective in patients with cluster headaches. These blockers help by regulating blood flow and reducing the frequency and intensity of migraine attacks.

The New Triptans

Since their first introduction in the 1990s, the Triptans revolutionized migraine treatment. Several newer formulations of triptans with different delivery forms have recently become available including:

RizaFilm (rizatriptan) oral film used as needed; adults may take a second 10 mg dose at least 2 hours after the first dose if needed, but no more than three 10 mg oral films can be taken in a 24 hour period.

Tosymra (sumatriptan) nasal spray; used as needed; no more than 30 mg to be taken in 24 hours (doses separated by at least one hour).

Zembrace SymTouch (sumatriptan) subcutaneous injection used as needed; no more than 12 mg to be taken in 24 hours (doses separated by at least one hour).

Onzetra Xsail (sumatriptan) nasal powder used as needed; no more than two doses (44 mg) to be taken in 24 hours (doses separated by at least two hours).

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CGRP Medications - New Frontier

CGRP inhibitors represent one of the most significant advances in migraine treatment in recent years, offering a targeted approach for both prevention and acute management. These have shown to reduce monthly migraine days by 4-6 days in chronic migraine patients. Recent developments include both injectable and oral CGRP inhibitors, expanding treatment options.

CGRP inhibitors target the calcitonin gene-related peptide (CGRP), a molecule found to play a crucial role in migraine pathophysiology. CGRP is involved in pain transmission and inflammation during migraine attacks. By inhibiting CGRP or its receptor, these drugs prevent the vasodilation and inflammation that contribute to migraine pain.

Acute Care CGRP Medications

The following medicines are approved by the FDA in the US for acute treatment of migraines:

Ubrelvy (Ubrogepant): This belongs to a class of drugs known as calcitonin gene-related peptide (CGRP) receptor antagonist (gepant). It's used as needed for the acute treatment of migraines with a second dose 2 hours after the initial dose; max 200 mg /day.

Nurtec (Rimegepant): Another oral medication from the gepant class, Nurtec, can be used for acute treatment of migraines in adults with a one time daily dose of 75 mg. 

Zavzpret (zavegepant) is a gepant nasal spray for the acute treatment of migraine with or without aura in adults. It is the only CGRP receptor antagonist available in a nasal spray form for patients who may not tolerate oral medications​.

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Preventative CGRP Medications

The following medicines are approved by the FDA in the US for prevention of migraines:

Nurtec (Rimegepant): In addition to being approved for acute use, Nurtec can be used every other day (75 mg dose) as a preventative treatment. Nurtec should not be uses more than 18 times per month.

Erenumab (Aimovig): A once-monthly subcutaneous injection approved for the preventive treatment of migraine in adults.

Fremanezumab (Ajovy): Available as a monthly or quarterly subcutaneous injection for the prevention of migraine in adults.

Galcanezumab (Emgality): Approved for the preventive treatment of migraine in adults, administered as a monthly subcutaneous injection.

Eptinezumab (Vyepti): An intravenous infusion given quarterly for the preventive treatment of migraine in adults.

Atogepant (Qulipta) is the first oral gepant used for prevention. It is dosed 10-60 mg/day for Episodic Migraine and 60 mg/day for Chronic Migraine.

These medications represent a new generation of migraine treatments and offer hope for those who haven't found relief with other therapies. However, it's important to consult with a healthcare provider to determine the best treatment plan based on individual health needs and medical history.

clear glass tube with brown liquid

Other Abortive Treatments

Apart from traditional medications like triptans and NSAIDs, several other abortive treatments have been developed for migraines. These treatments range from nasal sprays and neuromodulation devices to novel pharmacological agents, offering diverse options for patients who might not respond to conventional therapies. Their efficacy varies, but they provide essential alternatives, especially for those with contraindications to standard treatments.

Sprix (Toradol) is a nasal spray form of ketorolac, an NSAID. It's used for the short-term treatment of moderate to severe migraine pain. It provides rapid pain relief, typically within an hour, making it suitable for acute migraine attacks.

Trudhesa (DHE Nasal) is a nasal spray formulation of dihydroergotamine (DHE), a long-established migraine treatment. DHE is known for its effectiveness in treating acute migraines, with nasal administration offering a quicker onset of action compared to oral forms.

Reyvow (Lasmiditan) a selective serotonin receptor agonist that targets 5-HT1F receptors, distinct from the mechanism of triptans. It is particularly useful for patients who cannot use triptans due to cardiovascular concerns. Efficacy rates are comparable to triptans in reducing pain and associated symptoms.

Toradol, Reywow, Trudhesa shown in blue background

Safety and Important Considerations

When exploring options for migraine treatment, it's essential to consider the safety profiles and cautionary advice associated with various medications.

Please note that this information serves as a general overview, and individual responses to medications can vary. Always consult with a healthcare provider to tailor treatment to your personal health needs and understand the following common side effects.

CGRP Antagonists
Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality)
Common Side Effects: Injection site reactions, constipation, muscle spasms
Special Considerations: Generally well-tolerated; however, those with serious allergic reactions should avoid these medications. The safety of CGRP antagonists during pregnancy is not fully established, advising caution.

Ubrogepant (Ubrelvy), Rimegepant (Nurtec ODT)
Common Side Effects: Nausea, dry mouth, drowsiness
Special Considerations: Not recommended for individuals with severe liver disease due to potential risks.

Lasmiditan (Reyvow)
Common Side Effects: Dizziness, fatigue, "pins and needles" sensation, sleepiness
Special Considerations: Avoid use with alcohol or CNS depressants. Contraindicated for those with significant cardiovascular disease.

Sumatriptan (Imitrex), Rizatriptan (Maxalt)
Common Side Effects: Dizziness, tingling or prickling sensation, warmth or cold sensation
Special Considerations: Not suitable for individuals with certain cardiovascular conditions, uncontrolled hypertension, or those at risk of serotonin syndrome when combined with specific medications. While some studies suggest a small increased risk of birth defects, the overall risk is considered low. Use during pregnancy should be based on a careful benefit-risk assessment.

Dihydroergotamine (DHE)
Common Side Effects: Nausea, vomiting, muscle pain
Special Considerations: Contraindicated for individuals with certain cardiovascular conditions, uncontrolled hypertension, liver or kidney disease, and during pregnancy due to potential fetal harm.

Pregnancy Caution: The safety of CGRP antagonists, gepants, ditans, triptans, and DHE during pregnancy is not fully known, warranting avoidance or careful consideration.

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