Treating Migraine : Treatment with Medications

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I understand the importance of aborting a migraine attack early but what do I use to treat it?

There are a couple of possible approaches to treating your migraine: you may use analgesics to ease or relieve your pain or you may use abortive medications to stop the migraine attack. You can buy analgesics, such as acetaminophen, and some abortive medications, such as ibuprofen and aspirin, over the counter without a prescription. Stronger, more powerful medications both analgesics and abortive drugs—require a doctor’s prescription. Before you decide to treat your headaches and migraine attacks yourself, it is important that you have the diagnosis of migraine confirmed by a doctor.

I have a headache every day that I treat with over-the-counter analgesics but only have a migraine attack 4 to 8 times a month. Do I have medication overuse headache?

You may very well. Medication overuse headache can potentially be caused by either analgesics or abortive migraine medication. However, you can only confirm the diagnosis by stopping the medication in question and waiting to see if the daily headache disappears. Medication overuse is the most important risk factor for developing chronic daily headache (more than 15 headache days a month) and accounts for around 80 percent of those suffering from chronic daily headache. The overuse of analgesics or abortive medications hinders the effectiveness of migraine preventive medications. The treatment of severe migraine complicated with long-standing medication overuse requires the expertise of a headache specialist or a doctor experienced in treating severe headache disorders. It is not enough simply to treat the symptoms of a migraine attack or to abort it—you must prevent frequent attacks.

I take a medication for headache 4 to 5 times per week, but I do not think I have migraine. How can I know for sure?

You will need to stop taking your frequent medication in order to establish whether you have migraine or another headache disorder. You should also consult a doctor to make sure you do not have another medical disorder contributing to your frequent headaches. If you have migraine and you have stopped overusing abortive medications, you will find that you then start to have more typical migraine attacks. The overuse of abortive medication changes the symptoms of migraine and makes headaches appear as though they are tension or sinus-related headaches or even “daily” migraine.

What do people with migraine want their headache medication to do?

Studies have shown that people with migraine want the same thing their doctors do when it comes to headache relief or abortive medications: they want their medication to be effective. It needs to provide rapid and complete relief from the migraine attack and there should be no recurrence of the attack. People with migraine want the medication to be in tablet or capsule form and obviously prefer medications with no side effects. They do not want to have to be concerned about an attack preventing them from participating in work, social, or family activities.

How do I know whether I need a prescription medication or an over-the- counter drug?

You can determine your need for a prescription medication over one you can purchase over the counter by the effectiveness of the medication. If the over-the-counter medication completely aborts the migraine attack in less than 2 hours, then you do not need a prescription medication. However, if your attacks last longer than 2 hours, you do need to use a prescription migraine medication. This approach is called stratified care.

Q:	Why do I need my abortive medication to relieve my headache within 2 hours?
A:	You will need to abort the migraine attack as quickly as possible, since the longer you have a headache, the more the attack progresses. When you stop the headache, you treat the disease and help prevent the next attack. Severe migraine may require prescription medication to ensure that the attacks are stopped soon.

Medications used to treat a migraine attack

The medications used to treat a migraine attack can be classified into 2 main groups: those that treat the pain are called nonspecific and those that abort the attack are called specific. Medications used to treat the pain of a migraine attack are classified as simple analgesics, combination analgesics, or opioid analgesics. Specific medications used to abort a migraine attack are nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, and ergotamine-related medications. Note that aspirin is classified both as an NSAID and an analgesic. Medications that are used to treat nausea and vomiting (antiemetics) or cause relaxation (sedatives) are referred to as adjunctive therapies.

Table Nonspecific medications (pain relief)
Simple analgesics: Acetaminophen	Available over the counter
Combination analgesics: Aspirin or acetaminophen combined with other drugs	Many available over the counter
Opioid analgesics	Prescription only

Table Specific medications (abortive therapy)
Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin	Some available over the counter; most are prescription only
Triptans	Prescription only
Ergotamine-related medications	Prescription only

Table Adjunctive therapies
Antiemetics	Prescription only
Sedatives	Prescription only

Effective treatment

Headache-free results are more easily achieved when the attack is treated before central sensitization occurs. You will receive the greatest benefit from your migraine medication if you intervene early in the attack and use a fast-acting, effective medication that brings lasting relief. The medication should also be safe and ideally, should have no side effects. It may take time to find the right medication or the combination of medications needed to effectively treat your migraine attacks. Many of your migraine attacks may be mild enough to treat with over-the-counter medications such as acetaminophen, ibuprofen, or aspirin. However, more severe attacks will require prescription medication. Using effective abortive therapy (NSAIDs, triptans, or ergotamine-related medication) will reduce your need for excessive medication.

Fast relief

Medication must start to work quickly
Medication should provide headache-free response within 2 hours

Lasting relief

There should be low recurrence rates (headache does not return next day)
It should provide sustained headache-free response (headache does not return within 24 hours)
It should give consistent headache-free response (medication works for all attacks)