Fact sheet: Medications for the treatment of migraine attacks in adults

A migraine is not a “normal” headache. Most people have headaches from time to time – these are usually tension headaches. A migraine, though, is a sudden and strong, pounding headache on one side of the head. Some people only have occasional migraines. For others, migraines mean several days out of action every month, and it affects their quality of life a great deal.

Many people live with migraines without ever going to the doctor. But even if you manage your migraines with medicines that need no prescription, you still need to be careful about using too much medication.

Special anti-migraine drugs called triptans have been available since the early 1990s. They come in various forms. While any one of these will help more than half the people who take them, finding out what works best for your migraines can mean trying out several different medicines.

Read on to find out more about medicines for migraine attacks and the overuse of painkillers in adults. We have information about migraines in teenagers and children here. And we will add information on migraine prevention and non-medicine options for adults later.

What are migraines?

Migraines are usually moderate to severe headaches. They mostly only affect one side of the head, and are described as throbbing or thumping headaches. The pain is often made worse by physical activity or even a little movement. If left untreated, migraines last between 4 hours and 3 days, and may be associated with nausea and vomiting. Some people become extremely sensitive to sound, light and other kinds of sensory information during attacks.

Before the actual migraine symptoms become noticeable, some people see flashing lights and strange shapes, or their vision is distorted. For example, they might see everything as a blur or through wavy lines. Some people have trouble getting their words out correctly, experience paralysis or have abnormal feelings such as tingling. These things are collectively known as “auras”. Auras generally last up to one hour at the most, and then the typical migraine symptoms kick in.

14 out of 100 women and 8 out of 100 men in Germany have migraines. More than 1 out of every 4 women will have at least one migraine at some time in their lives (25%). Migraine attacks often occur again and again. It is not clear exactly what causes them. According to one theory, it has something to do with the blood vessels in the brain becoming inflamed, but this has not been proven to be true. It may also have something to do with pain perception in the brain.

Many young women start getting migraines first when they start having periods. A lot of women find that their migraine attacks stop during pregnancy. Those women usually stop getting migraines after the menopause too. In anyone who has migraines, the symptoms can sometimes get better on their own after a while. Some people take particular medication regularly to try to prevent or reduce their migraine attacks. We will report on those medications in another fact sheet in the future.

How do migraines generally affect people’s lives?

Many people have such strong or regular migraines that it makes their life difficult. Recurring migraines can really wear people down. Those who have bad migraines cannot keep going with their normal daily activities during an episode, and that affects their work and personal lives. Migraines can affect work performance and make it hard to concentrate. When people have to take a lot of time off work because of migraines, they sometimes worry about the effect on their jobs and careers.

Migraine attacks can happen at predictable times – around a woman’s monthly period for example. But they are often unpredictable, and that makes it difficult to plan social activities or stick to arrangements. It is not just the attacks themselves: people whose lives are frequently interrupted by sudden severe migraines might find that the fear of having an attack and worries about the social consequences affect their ability to enjoy life as well.

Negative feelings and thoughts can also lead to behavior that affects our quality of life - for example, if you avoid activities that you would normally really enjoy. A psychological approach called cognitive behavioral therapy (CBT) can help people change negative thought patterns and behavior. Some people may also try other psychological approaches, such as relaxation techniques, to help them cope better with migraines. These include things like autogenic training, where you learn to put yourself into a deep state of relaxation. Other people find that doing more physical exercise makes them feel better.

What can trigger a migraine?

One of the common strategies for coping with migraines is to keep a headache or migraine diary for a few weeks or a few months. You can use this kind of diary to write down or record:

• What happened around the time you got a migraine
• When the migraine started and when it was over
• How bad the migraine was
• When you took medication, what kind of medication and how much

Then if you think that something in particular is triggering your migraines, you can start keeping track of whether there really is a link. For instance, if you suspect that red wine might be a trigger, you could stop drinking it for a while and then look at your diary to see whether your migraines have got better or whether you have had fewer migraines since. Some of the things you might want to look out for that are thought to be triggers for migraines in at least some people include:

• Cheese, milk, red wine and chocolate
• Eggs
• Food additives: chemical substances that are added to particular foods, such as the artificial sweetener aspartame and the flavor enhancer monosodium glutamate

What are the drug treatment options for migraine attacks?

A lot of people who have migraines learn what they need to do to help them through attacks. This often means lying down in a quiet and dark room, or applying cool wet towels or cooling pads to the side of the head that hurts. Sometimes that is enough.

Especially if the migraine is very painful, most people will use one or more medications to help them through an attack. Which drug people use can depend on how serious the migraine attack is: a simple painkiller from a pharmacy might be enough for a mild attack. But a stronger medication might be needed for more severe migraines. People who have frequent migraines will often keep a variety of medications ready to be used if needed.

The types of medications most commonly used by adults with migraines are:

• Non-steroidal anti-inflammatory drugs (NSAIDs) such as acetylsalicylic acid (ASA, the drug in “Aspirin”), ibuprofen, diclofenac or naproxen, or painkillers like paracetamol
• Nausea medication like metoclopramide or domperidone
• Triptans: medications specifically made for migraines

Another substance that is the basis of some prescription drugs used for migraines is ergotamine, derived from the grain fungus called ergot. For almost a century this was the only specific medicine for migraine. It is not used as much these days though, because it has more adverse effects than the triptans.

Different medications serve different purposes. Some people mainly want relief as quickly as possible – they go for a drug that acts faster, even if another drug might provide more relief but takes longer to kick in. For other people, maximum relief is the most important thing, even if it takes a little longer to start working. People whose migraines last for a long time might prefer drugs whose effects also last longer. Some people’s options are limited: those with heart disease, for example, are advised not to use triptans.

How do triptans work?

Triptans are for migraine attacks, but are not intended for long-term daily use. Triptans are not painkillers. They affect a chemical process in the brain, and this in turn reduces migraine symptoms such as pain, nausea and light sensitivity. Each of the triptans have been shown to help more than half of all people with migraines, but they are not suitable for people who have cardiovascular (heart and circulation) diseases. This is because triptans narrow the blood vessels and they can increase blood pressure, although that is rare.

Seven different triptans are currently available in Germany: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan and zolmitriptan. Some of these drugs come in different forms, for example as tablets, capsules, nasal sprays, suppositories, injections and soluble tablets that are placed under the tongue. The triptans that have been available the longest in Germany are zolmitriptan and sumatriptan: they are also the most commonly used of these drugs. Triptans have to be prescribed by a doctor, apart from naratriptan, which is available in pharmacies without a prescription.

Although triptans all belong to the same “class” of drugs, there are several differences between them. They come in different doses, for example. Zolmitriptan tablets have 2.5 or 5 mg of triptan in them, while sumatriptan tablets have 50 mg or 100 mg in them. This is because there are small chemical differences between these drugs. The different triptans work a little differently. For example, some of them start working more quickly, while the effect of others lasts longer. This means that if one triptan does not help an individual person with their migraine as much as they would like, it could be worth trying another. Although triptans can provide relief to most of the people who take them, there are also many people who do not benefit much from them.

Triptans can cause adverse effects such as drowsiness, weakness and abnormal feelings such as pins and needles (a prickly feeling), warmth or chills. If they cause nausea, it could help to use suppositories or injections, because then the drug does not pass through the digestive system in the same way.

There has not been enough research to let us know with certainty which triptans work the fastest or the longest, or whether there is one that provides more relief from symptoms or causes fewer adverse effects. Rizatriptan might possibly work a little quicker than naratriptan and zolmitriptan. And eletriptan seems to relieve the symptoms somewhat better than naratriptan.

Sumatriptan relieves pain roughly as well as ASA does: both can reduce the pain and lower the risk of having another migraine within the next 24 hours. People who take ASA can take the anti-nausea drug (antiemetic) metoclopramide at the same time, to help reduce other migraine symptoms such as nausea and vomiting. Adverse effects are a little more common with sumatriptan than they are with ASA. You can read about research comparing triptans here.

How can medication best be used to lower the risk of the medication causing chronic headaches itself?

Taking too many headache drugs can cause a chronic headache. Headaches are considered to be chronic if they last longer than 14 days every month. It is not known exactly why this happens. But if it does happen, it can easily become a vicious circle. A person keeps taking more painkillers to relieve a headache, and the headache gets worse if they take less medication – so they take more again. If a person develops a chronic headache in this way (known as a “medication overuse headache”), then they will probably have withdrawal symptoms (including quite severe headaches) when they try to stop taking the medication.

Researchers estimate that 2 out of every 100 people in Germany (2%) have a chronic medication overuse headache. Frequent use of headache medicine is defined as using medication for headache on more than 10 days a month. People who use more than that are at risk of developing chronic headaches. People who have back pain in addition to headaches also seem to be at higher risk. Medication overuse headaches are more like migraines than tension headaches.

People who have developed chronic headaches from medication overuse will need to stop taking medicine completely for a while. That can solve the chronic headache problem, although it will probably not be easy.

Learning how to manage migraines while using less medication, so as to avoid developing chronic headaches, may seem difficult. But it is worth a try. Using lower doses less often, and finding other pain relief strategies - like relaxation techniques – could help. Medication is only part of the solution to living with migraine.

Author: German Institute for Quality and Efficiency in Health Care (IQWiG)

© IQWiG (Institute for Quality and Efficiency in Health Care)