Prescribed migraine medication
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Prescribed Migraine Medication: An Overview
Acute Migraine Treatment Options
Triptans and Dihydroergotamine
Triptans are a cornerstone in the acute treatment of migraines. Medications such as almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan (available in various forms including oral, nasal spray, injectable, and transcutaneous patch), and zolmitriptan (oral and nasal spray) have been shown to be highly effective (Level A evidence)1. Dihydroergotamine, available as a nasal spray and inhaler, is also effective (Level A), while other forms of dihydroergotamine and ergotamine are probably effective (Level B)1.
Non-Specific Medications
Non-specific medications such as acetaminophen, NSAIDs (aspirin, diclofenac, ibuprofen, and naproxen), and combination therapies (e.g., sumatriptan/naproxen, acetaminophen/aspirin/caffeine) are also effective for acute migraine treatment (Level A)1. Other medications like ketoprofen, intravenous and intramuscular ketorolac, and flurbiprofen are probably effective (Level B)1.
Opioids and Antiemetics
Opioids, including butorphanol nasal spray, codeine/acetaminophen, and tramadol/acetaminophen, are probably effective but are not recommended for regular use due to the risk of medication overuse headache (MOH) and other adverse effects1 8. Antiemetics such as prochlorperazine, droperidol, chlorpromazine, and metoclopramide are also probably effective (Level B)1.
Emergency Department Prescribing Patterns
A scoping review of medication prescribing patterns in emergency departments (ED) revealed a concerning trend of underutilization of triptans and overutilization of opioids for acute migraine treatment2. This deviation from established guidelines highlights the need for better adherence to evidence-based practices in the ED setting2.
Mechanisms of Action and Individualized Treatment
The choice of acute migraine medication should be individualized based on the characteristics of the migraine attack, the patient's medical history, and treatment preferences3. Understanding the pharmacodynamic and pharmacokinetic properties of these medications is essential for effective treatment3.
Adverse Effects and Safety Considerations
Physicians must consider both the efficacy and the potential adverse effects of migraine medications. For instance, while NSAIDs and triptans are effective, they can cause gastrointestinal issues and cardiovascular concerns, respectively4. Opioids, although effective, carry a high risk of dependency and MOH8.
Preventive Medications and Adherence
Preventive medications, such as beta-blockers, tricyclic antidepressants, and anticonvulsants, are recommended for patients with frequent migraines. However, adherence to these medications is often low, with significant drop-offs observed at six and twelve months5. This low adherence underscores the need for better patient education and follow-up.
Conclusion
Effective management of acute migraine involves a variety of pharmacological options, each with its own set of benefits and risks. Triptans and NSAIDs are generally first-line treatments, while opioids should be used sparingly. Adherence to preventive medications remains a challenge, necessitating ongoing patient support and education. Clinicians must tailor treatment plans to individual patient needs, considering both efficacy and safety to optimize outcomes.
Sources and full results
Most relevant research papers on this topic
The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies
Many acute migraine treatments have evidence supporting their efficacy, including triptans, dihydroergotamine, and various nonspecific medications.
Systematic Review
Rigorous Journal
Highly CitedAn Evaluation of Medication Prescribing Patterns for Acute Migraine in the Emergency Department: A Scoping Review
Emergency department treatment for acute migraines varies widely, with underutilization of triptans and overutilization of opiates, and non-adherence to established international guidelines.
Systematic ReviewRigorous JournalMigraine Treatment: Current Acute Medications and Their Potential Mechanisms of Action
Acute migraine medications aim to rapidly restore function with minimal recurrence and avoid side effects, with individualized treatment choices based on attack characteristics, patient preferences, and drug properties.
Very Rigorous JournalHighly CitedAdverse effects of medications commonly used in the treatment of migraine
Migraine medications can have both beneficial and harmful side effects, affecting coexisting conditions and requiring careful monitoring.
Adherence to oral migraine-preventive medications among patients with chronic migraine
Adherence to oral migraine-preventive medications is low among the US chronic migraine population at six months and worsens by 12 months.
Observational StudyRigorous JournalHighly CitedIbuprofen with or without an antiemetic for acute migraine headaches in adults.
Ibuprofen effectively reduces acute migraine headache symptoms and is well-tolerated by adults, with higher doses providing better relief.
Meta-AnalysisVery Rigorous JournalHighly CitedCurrent Prophylactic Medications for Migraine and Their Potential Mechanisms of Action
Current migraine preventive medications generally suppress excitatory nervous signaling, facilitate GABAergic inhibition, reduce neuronal sensitization, block cortical spreading depression, and/or reduce CGRP levels.
Very Rigorous JournalHighly CitedRisk of medication overuse headache across classes of treatments for acute migraine
Analgesics and opioids are associated with a higher risk of developing Medication Overuse Headache compared to triptans and ergots, suggesting a need for better monitoring of these treatments.
Rigorous JournalHighly CitedPreventive Treatment of Migraine
Preventive migraine treatment is often effective, but the choice depends on the individual's needs, preferences, and comorbid conditions.
Highly CitedAcute Migraine Treatment in Adults
Acetaminophen, NSAIDs, and triptans are effective acute migraine treatments, but individualized treatment plans are needed based on patient features and contraindications.
Literature ReviewRigorous JournalHighly Cited