Prescription medications for migraine relief.
Prescription medications for migraine relief are often required when over-the-counter (OTC) treatments fail to provide adequate relief or when migraines are frequent, severe, or disabling. These prescription options can be classified into two main categories: acute (abortive) treatments, which are used during a migraine attack to relieve symptoms, and preventive (prophylactic) treatments, which are taken regularly to reduce the frequency and severity of migraines.
1. Acute (Abortive) Medications
Acute medications aim to stop or reduce the symptoms of a migraine once it begins. They are most effective when taken early in the attack and include a variety of drug classes:
a. Triptans
Triptans are the most common class of prescription drugs used for acute migraine treatment. They work by stimulating serotonin (5-HT) receptors, which constrict blood vessels and reduce inflammation, stopping the migraine process.
- Common triptans include:
- Sumatriptan (Imitrex): Available in oral, nasal spray, and injectable forms, sumatriptan is effective for many migraine sufferers. It’s typically taken at the first sign of a migraine.
- Rizatriptan (Maxalt): This drug is fast-acting and can be taken as a dissolvable tablet, making it easier to consume during a migraine.
- Zolmitriptan (Zomig): Available in tablet and nasal spray forms, it works similarly to other triptans and is often used when migraine symptoms come with nausea or vomiting.
- Eletriptan (Relpax) and Almotriptan (Axert) are other common triptans.
Side Effects: Triptans can cause side effects like chest tightness, dizziness, nausea, and drowsiness. They are not recommended for individuals with cardiovascular disease due to the risk of constricting blood vessels, which can lead to heart complications.
b. Ergot Alkaloids
Ergot alkaloids are another class of migraine-specific medications, although they are generally less preferred than triptans due to more side effects.
- Dihydroergotamine (DHE 45, Migranal): Available as an injection or nasal spray, dihydroergotamine is effective for severe migraines, especially those that don’t respond well to triptans. It works by constricting blood vessels and blocking pain pathways.
- Ergotamine (Ergomar): Typically taken with caffeine, it’s used for migraines but may cause nausea and vomiting. It’s considered less effective and has more side effects than triptans.
Side Effects: Ergot alkaloids can cause nausea, vomiting, muscle pain, and numbness. Like triptans, they are contraindicated in individuals with cardiovascular disease.
c. CGRP (Calcitonin Gene-Related Peptide) Receptor Antagonists
A newer class of drugs, CGRP antagonists, target a protein involved in migraine attacks. These drugs block the CGRP receptor, preventing the protein from triggering the pain and inflammation that lead to migraines.
- Ubrogepant (Ubrelvy): An oral medication taken during a migraine attack to block CGRP activity and stop the migraine.
- Rimegepant (Nurtec ODT): Available as an orally dissolvable tablet, it can both treat migraines and, in some cases, prevent future attacks.
Side Effects: CGRP antagonists typically have fewer side effects compared to triptans and ergot alkaloids, though they may cause nausea or dry mouth.
d. Ditans
Ditans are a new class of migraine medications that, like triptans, target serotonin receptors, but they work more selectively, which reduces the risk of cardiovascular side effects.
- Lasmiditan (Reyvow): This is an oral tablet used to treat acute migraines. It doesn’t constrict blood vessels, making it a safer option for those with heart disease or high blood pressure.
Side Effects: Common side effects of lasmiditan include dizziness, fatigue, and sleepiness. It can impair the ability to drive for up to 8 hours after use.
e. Anti-Nausea Medications (Antiemetics)
Nausea and vomiting are common symptoms of migraines. Prescription anti-nausea medications, also known as antiemetics, are often combined with other migraine medications to improve comfort.
- Metoclopramide (Reglan): This drug not only helps with nausea but can also improve the effectiveness of other migraine medications by aiding in their absorption.
- Prochlorperazine (Compazine): Another anti-nausea medication often prescribed during migraine attacks, particularly in emergency settings.
Side Effects: These medications can cause drowsiness, dizziness, and restlessness.
f. Opioids and Barbiturates
Opioid medications like codeine or hydrocodone and barbiturates like butalbital (often found in combination drugs such as Fioricet) are sometimes prescribed for migraine relief. However, these drugs are generally avoided due to their risk of dependency, rebound headaches, and limited effectiveness compared to other migraine-specific treatments.
2. Preventive (Prophylactic) Medications
Preventive medications are taken daily, regardless of whether a migraine is present, to reduce the frequency, severity, and duration of migraines. They are recommended for individuals who experience frequent migraines (e.g., more than four a month) or whose migraines significantly interfere with daily life.
a. Beta-Blockers
Beta-blockers, traditionally used for high blood pressure and heart disease, have been shown to reduce the frequency and severity of migraines.
- Propranolol (Inderal): The most commonly prescribed beta-blocker for migraines. It works by reducing the excitability of nerve cells involved in migraine attacks.
- Metoprolol (Lopressor) and Atenolol (Tenormin) are other beta-blockers sometimes used for migraine prevention.
Side Effects: Beta-blockers can cause fatigue, dizziness, and cold extremities. They may not be suitable for people with asthma or other respiratory conditions.
b. Antidepressants
Certain antidepressants, particularly tricyclic antidepressants (TCAs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), can help prevent migraines.
- Amitriptyline (Elavil): A tricyclic antidepressant that reduces migraine frequency by altering neurotransmitter levels.
- Venlafaxine (Effexor): An SNRI that can also help reduce the frequency of migraines.
Side Effects: These medications can cause drowsiness, weight gain, and dry mouth.
c. Anticonvulsants
Originally developed to treat epilepsy, anticonvulsants can help prevent migraines by stabilizing nerve cell activity.
- Topiramate (Topamax): One of the most effective medications for preventing migraines, though it can take a few months to show full benefits.
- Valproate (Depakote): Another anticonvulsant sometimes used for migraine prevention, though it may have more side effects than topiramate.
Side Effects: Anticonvulsants can cause side effects like dizziness, cognitive difficulties, weight loss (Topiramate), or weight gain (Valproate).
d. CGRP Inhibitors
CGRP inhibitors can also be used preventively. These drugs block CGRP, a protein linked to migraines, to reduce the frequency of attacks.
- Erenumab (Aimovig), Fremanezumab (Ajovy), and Galcanezumab (Emgality): These are injected once a month or quarterly to prevent migraines.
Side Effects: Generally well-tolerated, though they may cause injection site reactions or constipation.
e. Botox (OnabotulinumtoxinA)
Botox injections are approved for chronic migraine prevention, particularly in individuals experiencing 15 or more headache days a month. Botox is injected into specific areas of the head and neck every 12 weeks.
Side Effects: Common side effects include neck pain, muscle weakness, and injection site reactions.
Conclusion
Prescription medications for migraines are available in both acute and preventive forms, targeting different mechanisms to either stop a migraine in its tracks or reduce its frequency. While acute treatments like triptans and CGRP antagonists provide fast relief, preventive options like beta-blockers, antidepressants, anticonvulsants, and Botox can help manage chronic migraines. It’s important to work with a healthcare provider to identify the most effective and safe treatment based on individual migraine patterns and overall health.
