MIGRANE

Headache Medications

Headache pain may need to be managed with medications. Medications used to treat headache pain can be grouped into three different categories:

• Symptomatic relief
• Abortive therapy
• Preventive therapy

Each type of medication is most effective when used in combination with other medical recommendations, such as dietary and lifestyle changes, exercise, and relaxation therapy.

The goal of medication therapy for headaches is to relieve the pain and prevent future attacks.

What Medications Offer Symptomatic Relief?

Symptomatic relief medications are used to relieve symptoms associated with headaches, including the pain of a headache or the nausea and vomiting associated with migraines.

Many of these medications are available over-the-counter, without a doctor's prescription. Other medications require a prescription. When taking these medications, avoid excessive caffeine-containing products and medications. Any medication containing barbiturates (butalbital) or narcotics (codeine) should be used sparingly.

Decongestant medications can be used to relieve headaches associated with sinus infections. Decongestants help relieve headache symptoms because they constrict (narrow) blood vessels that cause headache pain. However, decongestant use can be habit-forming. If your headaches seem to be relieved by decongestants but you do not have a sinus infection, you may actually have a migraine or tension-type headache, which require treatment with abortive or preventive medications (see below).

Note: if symptomatic relief medications are used more than twice a week, you should see your doctor who can prescribe preventive headache medications. Overuse of symptomatic medications can actually cause more frequent headaches or worsen headache symptoms.

Over-the-counter medications for symptomatic relief include:

Guidelines for Using Over-the-Counter Pain Relievers

Nonprescription pain-relievers have been demonstrated to be safe when used as directed. But, keep the following precautions in mind:

• Know the active ingredients in each product. Be sure to read the entire label.
• Do not exceed the recommended dosage on the package.
• Carefully consider how you use pain-relievers and all medications: it is easy to over-medicate yourself.
• Check with your doctor before taking products containing, aspirin (Excedrin), ibuprofen (Motrin) or naproxen (Aleve, Naprosyn) if: you have a bleeding problem; asthma; recently had surgery or dental surgery or are about to have surgery; have ulcers, kidney or liver disorders; take any other nonsteroidal anti-inflammatory medications (NSAIDs), such as ibuprofen or naproxen.
• Check with your doctor before taking acetaminophen-containing products (Tylenol) if you have kidney or liver problems.

Prescription medications for symptomatic relief include:

What Are Abortive Medications?

Abortive medications, when used at the first sign of a migraine, can stop the process that causes the headache pain. By stopping the headache process, abortive medications help prevent the symptoms of migraines including pain, nausea, and sound and light sensitivity. Some medications should not be used during a migraine aura; please follow the instructions of your doctor.

The following medications are used to stop the headache process.

What Is Preventive Therapy?

Preventive medications, prescribed to take on a daily basis, are used to treat very frequent tension headaches and migraines, or the combination of both types of headaches. Preventive treatment is aimed at reducing both the frequency and severity of the headaches.

To be effective, all preventive medications must be taken one or more times every day. It may be necessary for your doctor to change the medications and modify their dosages in order to discover which medication or combination of medications, and at which dosages, work best to reduce the frequency and severity of your headache pain.

While you are taking preventive medications, carefully recording your headache frequency and severity on a daily basis will help your doctor judge how the medications are working. Most of these medications require days to weeks to become effective.

Once good headache control has been achieved and maintained for 6 months or a year, it may be possible to taper and stop these medications. In other cases, it may be necessary to take the medications for a longer period of time. Your doctor will provide the recommendations that are right for you.

The medications listed include both over-the-counter and prescription drugs. These drugs are not habit-forming, but any medication can cause unwanted side effects. Your doctor will work with you to carefully regulate the dosage so that side effects are minimized and headache relief is maximized.

Medications for Preventive Therapy

What Other Medications May Be Used?

Botox injections have been used in clinical trials for the treatment of migraines.

Tips for Taking Your Medications

You and your doctor are partners in developing, adjusting and following an effective medication plan. Make sure that you understand and share the same treatment goals as your doctor. Talk about what you expect from medications so you can know if your treatment plan is working.

Here are some general guidelines:

• Before any medication is prescribed, tell your doctor if you have any allergies. Also tell your doctor about all other medications you are taking including over-the-counter medications, vitamins and herbal products.
• Know the names of your medications and how they work. Know the generic and brand names, dosages and side effects of your medications. Always keep a list of your medications with you.
• Know what side effects to expect from your medications. Call your doctor if you experience unexpected or troubling side effects.
• Take your medications exactly as prescribed, at the same time(s) every day. Do not stop taking or change your medications unless you first talk with your doctor. Even if you feel good, continue to take your medications. Stopping your medications suddenly can make your condition worse.
• Have a routine for taking your medications. Get a pillbox that is marked with the days of the week. Fill the pillbox at the beginning of each week to make it easier for you to remember.
• Keep a medicine calendar and note every time you take a dose. Your prescription label tells you how much to take at each dose, but your doctor may change your dosage periodically, depending on your response to the medication. On your medication calendar, you can list any changes in your medication dosages as prescribed by your doctor.
• Take your time. Double-check the name and dosage of all your medications before taking them.
• Regularly fill your prescriptions and ask your pharmacist any questions you have about refilling your prescription. Know your pharmacy phone number, prescription number, medication name and dose so you can easily call for refills. Try to fill all your prescriptions at the same pharmacy, so the pharmacist can monitor for interactions and provide proper dosing and refills.
• Do not wait until you are completely out of medication before filling your prescriptions; call the pharmacy or doctor's office at least 48-hours before running out. If you have trouble getting to the pharmacy, have financial concerns or have other problems that make it difficult for you to get your medications, let your doctor know. A social worker may be available to help you.
• If you forget to take a dose, take it as soon as you remember. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take two doses to make up for the dose you missed.
• Do not decrease your medication dosage to save money. You must take the full amount to get the full benefits. Talk with your doctor about ways you can reduce the costs of your medications.
• If you have prescription coverage, make sure you know the terms of your policy. Remind your doctor about the type of insurance coverage you have.
• Do not stop taking your medication unless your doctor tells you to. If you have concerns about your medication and how it is working, talk to your doctor.
• Keep medications stored in their original containers. Store according to the instructions given with the prescription.
• Check liquid medications often. If they have changed color or formed crystals, throw them away and get new ones.
• Do not take any over-the-counter drugs or herbal therapies unless you ask your doctor first.
• When traveling, keep your medications with you so you can take them as scheduled. On longer trips, take an extra week's supply of medications and copies of your prescriptions, in case you need to get a refill.
• The way the body responds to medications may change over time, so your medications may need to be adjusted. Tell your doctor if you notice a difference in how well the treatment plan is working.

Next: Alternative Therapy >

Reviewed by Department of Neurology, The Cleveland Clinic.

Medically reviewed by Charlotte E. Grayson, MD, Dec. 2001, WebMD.

Copyright ©2002 content, The Cleveland Clinic. The information provided by The Cleveland Clinic is not intended to replace the medical advice of your doctor or health-care provider. Please consult your health-care provider for advice about a specific medical condition. For additional health information, please contact the Health Information Center at The Cleveland Clinic, (216) 444-3771 or toll-free (800) 223-2273, Ext. 43771.

© 2002 WebMD Inc. All rights reserved.

A substantive amendment to this systematic review was last made on 23 August 2000. Cochrane reviews are regularly checked and updated if necessary.

Background: There are a number of different drug treatments for acute migraine, including currently four triptans, with several more likely to become available in the future. There is a need for evidence-based information to help determine the balance of benefit and harm for acute migraine treatment.

Objectives: To quantitatively assess the efficacy of a single dose of rizatriptan (Maxalt) for treating a single migraine attack using the outcomes of headache response and pain-free response at half-an-hour, one hour, two hours, and sustained relief over 24 hours. To express efficacy in terms of numbers-needed-to-treat (NNTs).

Search strategy: Trials were identified by searching MEDLINE (1966-July 2000), EMBASE (1980-June 2000), the Cochrane Library (Issue 3, 2000) and the Oxford Pain Relief Database (1950-1994). Date of last search: July 2000.

Selection criteria: The inclusion criteria were randomised, placebo-controlled trials of rizatriptan for acute migraine; double-blind design; International Headache Society diagnostic criteria for migraine with or without aura; single migraine attack; single-dose treatment at standard doses; adult population; baseline pain of moderate or severe intensity using a four-point standardised rating scale; dichotomous or percentage data for at least one of the main efficacy outcomes; and full journal publication.

Data collection and analysis: Main outcomes considered were i) headache response at two hours, ii) headache response at one hour, iii) pain-free response at two hours, iv) sustained relief over 24 hours, v) pain-free response at 24 hours and vi) adverse effects. Minor outcomes were headache response and pain-free response at half-an-hour and four hours, and pain-free response at one hour.

Dichotomous or percentage data were extracted and used to calculate the relative benefit (RB) and number-needed-to-treat (NNT) for each outcome.

Main results: Seven trials met our inclusion criteria, with 2626 patients given rizatriptan and 902 given placebo. Significant benefit of rizatriptan over placebo was shown for both doses of rizatriptan (5 mg and 10 mg) for all five main efficacy outcomes (ranging from one to 24 hours). A dose response was seen for the main outcomes. It was not possible to analyse adverse effects information in a meaningful way.

Reviewers' conclusions: Rizatriptan 5 mg and 10 mg are effective in treating acute migraine, with a dose-related increase in efficacy.

Citation: Oldman AD, Smith LA, McQuay HJ, Moore RA. Rizatriptan for acute migraine (Cochrane Review). In: The Cochrane Library, Issue 4 2002. Oxford: Update Software.

A substantive amendment to this systematic review was last made on 25 August 2000. Cochrane reviews are regularly checked and updated if necessary.

Background: Eletriptan (Relpax) is a new triptan soon to be made available by prescription for the treatment of acute migraine. Currently five triptans are available by prescription and more are under development. In light of the many drugs for treating acute migraine, there is a need for evidence-based assessments to help determine the relative efficacy and harm of these treatments.

Objectives: To determine the efficacy of eletriptan for treating a single migraine attack using the outcomes of headache response and pain-free response at 0.5, 1, 2 and 4 hours, and sustained relief over 24 hours. To express efficacy in terms of number-needed-to-treat (NNT). To determine the adverse effects of a single dose of eletriptan and express this in terms of number-needed-to-harm (NNH). To allow for the comparison of the efficacy of eletriptan with other migraine treatments evaluated systematically in the same way.

Search strategy: Data from all Phase III randomised placebo-controlled trials were made available by the manufacturer, Pfizer Inc. To date, these trials comprise the only data on eletriptan relevant to this review in a published or unpublished form; thus, searches of electronic databases for further trials of eletriptan were not conducted. Date of last search: January 2000.

Selection criteria: Trials of eletriptan for acute migraine; randomised allocation to treatment groups, including a placebo group; double-blind design; International Headache Society diagnostic criteria for migraine with or without aura; single migraine attack; single-dose treatment at standard doses; adult population; baseline pain of moderate or severe intensity using a 4-point standardised rating scale (0 = no pain, 1 = mild pain, 2 = moderate pain and 3 = severe pain); and dichotomous or percentage data for at least one of the main efficacy outcomes.

Data collection and analysis: Trials were scored for quality and data extracted by two independent reviewers. Dichotomous or percentage data were extracted and pooled to calculate the relative benefit (RB) or relative risk (RR) and NNTs or NNHs for a number of outcomes for eletriptan 20 mg, 40 mg and 80 mg. The main outcomes considered were headache response at 1 and 2 hours, pain-free response at 2 hours, sustained relief over 24 hours and adverse effects. Minor outcomes considered were headache response at 0.5 and 4 hours, and pain-free response at 0.5, 1 and 4 hours.

Main results: Six trials met the inclusion criteria. Significant benefit of eletriptan over placebo was shown for eletriptan 20 mg, 40 mg and 80 mg for the primary efficacy outcomes of headache response and pain-free response at 2 hours. For headache response at 2 hours, the NNTs (with 95% confidence intervals) were 4.4 (3.4 to 6.2), 2.9 (2.6 to 3.3) and 2.6 (2.4 to 3.0) for eletriptan 20 mg, 40 mg and 80 mg, respectively. For pain-free response at 2 hours, the NNTs were 9.9 (6.9 to 18), 4.0 (3.6 to 4.5) and 3.7 (3.4 to 4.2), for eletriptan 20 mg, 40 and 80 mg, respectively.

There was no significant difference in the incidence of major adverse effects between any dose of eletriptan and placebo. The incidence of minor adverse effects was significantly higher for all eletriptan doses than for placebo, with NNHs of 11 (95% confidence interval, 6.2 to 39), 7.0 (5.2 to 11) and 3.7 (3.1 to 4.5) for eletriptan 20 mg, 40 mg and 80 mg, respectively.

Reviewers' conclusions: Eletriptan 20 mg, 40 mg and 80 mg are effective for the treatment of an acute migraine attack. Effectiveness is dose-related, with statistically significant differences between doses for pain-free response and 24-hour outcomes. Eletriptan compares well with other triptans available for outcomes measured up to 2 hours and provides meaningful relief for 24 hours. Taken as a single dose, eletriptan was well tolerated and caused no major harm. The incidence of minor harm was dose-dependent, with 80 mg giving significantly more adverse effects than 40 mg.

Citation: Smith LA, Oldman AD, McQuay HJ, Moore RA. Eletriptan for acute migraine (Cochrane Review). In: The Cochrane Library, Issue 4 2002. Oxford: Update Software.