Medications for Treating Migraine Attacks:

Many different medications are used to treat migraines. However, the Food and Drug Administration (FDA) has specifically approved only the following types of drugs for treating migraine attacks:

• Non-prescription drugs: Excedrin Migraine, Advil Migraine, Motrin Migraine Pain
• Prescription drugs: Triptans and ergotamine

Other types of drugs, including opioids and barbiturates, are sometimes prescribed off-label for migraine treatment. Opioids and barbiturates have not been approved by the FDA for migraine relief, and they can be addictive.

All FDA-approved migraine treatments are approved only for adults. No migraine products have officially been approved for use in children.

Pain Relievers

Some patients with mild migraines respond well to over-the-counter (OTC) painkillers, particularly if they take the medicine at the very first sign of an attack. OTC pain relievers, (also called analgesics), include:

• Nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin. The FDA-approved migraine products Advil Migraine and Motrin Migraine Pain both contain ibuprofen.
• Acetaminophen (Tylenol). The FDA-approved migraine product Excedrin Migraine contains acetaminophen, as well as aspirin and caffeine.

There are also prescription-only NSAIDs. These include diclofenac (Cataflam), which is taken by mouth, and ketorolac (Toradol), which is given by injection.

NSAID Side Effects. High dosages and long-term use of NSAIDs can increase the risk for heart attack, stroke, kidney problems, and stomach bleeding. Aspirin does not increase the risk for heart problems, but it can cause other NSAID-related side effects.

Triptans

Triptans (also referred to as serotonin agonists) were the first drugs specifically developed for use against migraine. They are the most important migraine drugs currently available. They help maintain serotonin levels in the brain, and so specifically target one of the major components in the migraine process.

Triptans are recommended as first-line drugs for adult patients with moderate-to-severe migraines when NSAIDs are not effective. Triptans have the following benefits:

• They are effective for most patients with migraine, as well as patients with combination tension and migraine headaches.
• They do not have the sedative effect of other migraine drugs.
• Withdrawal after overuse appears to be shorter and less severe than with other migraine medications

Sumatriptan. Sumatriptan (Imitrex) has the longest track record and is the most studied of all triptans. It is available as a fast-dissolving pill, nasal spray, or injection. Injected sumatriptan works the fastest of all the triptans and is the most effective, but it can cause pain at the injection site. The nasal spray form bypasses the stomach and is absorbed more quickly than the oral form. Some patients report relief as soon as 15 minutes after administration. The spray tends to work less well when a person has nasal congestion from cold or allergy. It may also leave a bad taste. Sumatriptan is effective for many patients, but headache recurs in 20 - 40% of people within 24 hours after taking the drug.

In 2008, the FDA approved a drug (Treximet) that combines in one pill both sumatriptan and the anti-inflammatory pain reliever naproxen (Aleve, Naprosyn). Some studies have found that the combination of sumatriptan and naproxen works better for migraine relief than either drug alone.

Other Triptans. Newer triptans include almotriptan (Axert), zolmitriptan (Zomig), naratriptan (Amerge), rizatriptan (Maxalt), frovatriptan (Frova), and eletriptan (Relpax). Comparison studies with sumatriptan suggest that some of the newer drugs may have fewer side effects and may be better for providing immediate, sustained, and consistent pain relief. Triptans are also being investigated for prevention under certain circumstances, such as menstrual migraines, but benefits appear limited.

Although triptans, (like all migraine medications), are approved only for adults, researchers are investigating zolmitriptan for treating migraines in adolescents.

Side Effects. Side effects of triptans may include:

• Tingling and numbness in the toes
• Sensations of warmth
• Discomfort in the ear, nose, and throat
• Nausea
• Drowsiness
• Dizziness
• Muscle weakness
• Heaviness, pain, or both in the chest. (About 40% of patients taking sumatriptan experience these symptoms, and they are major factors in discontinuing the drug. Newer drugs, such as almotriptan, produce fewer chest symptoms.)
• Rapid heart rate

Complications of Triptans. The following are potentially serious problems.

• Complications of heart and circulation. Triptans narrow (constrict) blood vessels. Because of this effect, spasms in the blood vessels may occur and cause serious side effects, including stroke and heart attack. Such events are rare, but patients with an existing history or risk factors for these conditions should generally avoid triptans.
• Serotonin syndrome. Serotonin syndrome is a life-threatening condition that occurs from an excess of the brain chemical serotonin. Triptan drugs used to treat migraine, as well as certain types of antidepressant medications, can increase serotonin levels. These antidepressant drugs include serotonin reuptake inhibitors (SSRIs) -- such as fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) -- and selective serotonin/norepinephrine reuptake inhibitors (SNRIs), such as duloxetine (Cymbalta) and venlafaxine (Effexor). It is very important that patients not combine a triptan drug with a SSRI or SNRI drug. Serotonin syndrome is most likely to occur when starting or increasing the dose of a triptan or antidepressant drug. Symptoms include restlessness, hallucinations, rapid heartbeat, tremors, increased body temperature, diarrhea, nausea, and vomiting. You should seek immediate medical care if you have these symptoms.

The following people should avoid triptans or take them with caution and only with the advisement of a doctor:

• Anyone with a history or any risk factors for stroke, uncontrolled diabetes, high blood pressure, or heart disease.
• People taking antidepressants that increase serotonin levels.
• Children and adolescents. They may be safe, but controlled studies are needed to confirm this. (Triptans should not, in any case, be the first-line treatment for children.)
• People with basilar or hemiplegic migraines. (Triptans are not indicated for these migraineurs.)
• There is no evidence to date of any higher risk for birth defects in pregnant women who take triptans. Still, women should be cautious about taking any medications during pregnancy and discuss any possible adverse effects with their doctors.

Ergotamine (Ergot)

Drugs containing ergotamine (commonly called ergots) constrict smooth muscles, including those in blood vessels, and are useful for migraine. They were the first anti-migraine drugs available. Ergotamine is available by prescription in the following preparations:

• Dihydroergotamine (DHE) is an ergot derivative. It is administered as a nasal spray form (Migranal) or by injection, which can be performed at home.
• Ergotamine is available tablets taken by mouth, tablets taken under the tongue (sublingual), and rectal suppositories. Some of the tablet forms of ergotamine contain caffeine.

Ergotamine ' s role since the introduction of triptans is now less certain. Only the rectal forms of ergotamine are superior to rectal triptans. Injected, oral, and nasal-spray forms are all inferior to the triptans. Ergotamine may still be helpful for patients with status migrainous or those with frequent recurring headaches.

Side Effects. Side effects of ergotamine include:

• Nausea
• Dizziness
• Tingling sensations
• Muscle cramps
• Chest or abdominal pain

The following are potentially serious problems:

• Toxicity. Ergotamine is toxic at high levels.
• Adverse effects on blood vessels. Ergot can cause persistent blood vessel contractions, which may pose a danger for people with heart disease or risk factors for heart attack or stroke.
• Internal scarring (fibrosis). Scarring can occur in the areas around the lungs, heart, or kidneys. It is often reversible if the drug is stopped.

The following patients should avoid ergots:

• Pregnant women. Ergots can cause miscarriage.
• People over age 60.
• Patients with serious, chronic health problems, particularly those of the heart and circulation.

Ergotamine can interact with other medications, such as antifungal drugs and some antibiotics. All ergotamine products approved by the Food and Drug Administration (FDA) contain a "black box" warning in the prescription label explaining these drug interactions. In 2007, the FDA pulled 15 unapproved older ergotamine products off the market, in part because they lacked this warning label. The five FDA-approved ergotamine products that remain on the market are:

• Migergot suppository (marketed by G and W Labs)
• Ergotamine Tartrate and Caffeine tablets (marketed by Mikart and West Ward)
• Cafergot tablets (marketed by Sandoz)
• Ergomar sublingual tablets (marketed by Rosedale Therapeutics)

Opioids

If the pain is very severe and does not respond to other drugs, doctors may try painkillers containing opioids. Opioid drugs include morphine, codeine, meperidine (Demerol), and oxycodone (Oxycontin)]. Butorphanol is an opioid in nasal spray form that may be useful as a rescue treatment when others fail.

Opioids are not approved for migraine treatment and should not be used as first-line therapy. Nevertheless, many opioid products are prescribed to patients with migraine, sometimes with dangerous results. In 2007, following reports of several drug-related deaths, the Food and Drug Administration warned that the cancer pain pill fentanyl (Fentora) should not be used to treat patients with migraine or others conditions for which the drug is not specifically approved.

Side Effects. Side effects for all opioids include drowsiness, impaired judgment, nausea, and constipation. There is a risk for addiction, and these drugs can become ineffective with long-term use for chronic migraines. Doctors should not prescribe opioids to patients at risk for drug abuse, including those with personality or psychiatric disorders.

Drugs Used for Nausea and Vomiting

Metoclopramide (Reglan) is used in combinations with other drugs to treat the nausea and vomiting that occurs with other drugs and with migraine itself. Metoclopramide and other anti-nausea drugs, such as domperidone (Motilium), may help the intestine better absorb migraine medications.