Migraine meds letting you down? Maybe it's time for a change.
Treatments like nonsteroidal anti-inflammatory drugs (NSAIDs) and triptans can be very effective, but they don’t work for everyone. Even if they brought you relief in the past, they may not work as well as they used to.
Migraine and its triggers can change as you age, so it makes sense that your treatment may need to change, too.
You have several types of medication, as well as nondrug options, to choose from.
NSAIDs and Triptans
People with mild to moderate migraine commonly start off taking NSAIDs like ibuprofen or naproxen, in either over-the-counter or prescription strengths. These drugs are abortive, which means they stop migraine headaches once they've begun. They do this by blocking the inflammation that causes them.
If you have moderate to severe migraine, or if NSAIDs don't work for you, your doctor may start you on triptan drugs. These stop headaches by reducing inflammation and narrowing your blood vessels, both key factors in a migraine. (Because of their effect on blood vessels, they aren't recommended for people with cardiovascular problems like a history of stroke or heart disease.)
If the triptan drug you've been taking no longer helps, you may benefit from trying a different triptan. Although all work in a similar way, some work faster and some last longer than others. You can also ask your doctor whether a different dose or different method of taking the drug could help.
In addition to oral tablets, you can take triptans as a shot or nasal spray. Some triptans are:
Not everyone responds the same way to a particular drug, and it can take some trial and error to find what works best for you. Side effects are a consideration, too. Your doctor can help you decide if you should switch your triptan or explore another type of treatment.
CGRP inhibitors, Lasmiditan and Ergots
If NSAIDs and triptans don’t work, or if you can’t tolerate triptans, your doctor may suggest a "second-line" treatment. Among the newer treatments for migraine are CGRP inhibitors and the drug Lasmiditan (Reyvow). These drugs target specific nerve endings (receptors) to ease symptoms. You can take them at the first sign of migraine.. These drugs target specific nerve endings (receptors) to ease symptoms. You can take them at the first sign of migraine.
Lasmiditan (Reyvow) can cross your blood-brain barrier like triptans, but it doesn't narrow blood vessels like triptans do so it can be taken by people who can’t take triptans because of their history of heart disease or stroke. When taking this medicine you’ll have to avoid driving or operating heavy machinery for at least 8 hours. .
CGRP inhibitors don’t constrict blood vessels. That means you may be able to use them for acute migraine if you’ve had heart disease, heart disease or stroke. These drugs include:
- Rimegepant (Nurtec)
- Ubrogepant (Ubrelvy)
- Zavegepant (Zavzpret)
Other CGRP antagonists are approved for preventing migraines.
Ergots, or ergot alkaloids, have been around for decades but they have side effects and don’t work as well as triptans so they aren’t used much. They constrict blood vessels. So they're not for people who have heart or vascular problems or kidney disease, or for those who have long auras. (Auras are disturbances to your senses, like vision problems, that happen before or during a migraine headache.)
How Second-Line Drugs Work With Other Medications
Not all migraine attacks are alike. Some need a lot more intervention than others.
Having second-line drugs can help when your main medication fails or when your symptoms return hours later. They can also be useful for those mornings when you wake up with a full-blown migraine.
In some cases, you can take two or more medications together at the start. For example, studies suggest that using a triptan such as sumatriptan with an NSAID such as naproxen may be more effective than using either alone.
But drugs can interact with each other or worsen side effects. For instance, you shouldn’t take one or more ergots and/or triptans within 24 hours of each other. That’s why it’s important to discuss drug combinations with your doctor or pharmacist.
Preventive Treatments for Migraine
If you have lots of migraine attacks, or if they make it hard for you to function in daily life, it may be time to consider preventive therapy. You take or get these treatments regularly to stop headaches from starting in the first place.
Which one is right for you depends on factors such as how often you get migraines and how bad they are, as well as other health conditions you may have. Some oral medications that help prevent migraine are:
- Antidepressants such as amitriptyline
- Anti-seizure drugs such as topiramate and valproate
- Beta-blockers such as metoprolol tartrate and propranolol
- Calcium channel blockers such as verapamil
- CGRP inhibitors such as rimegepant (Nurtec) and atogepant (Qulipta)
CGRP inhibitors that are given monthly or quarterly by self injection or IV include eptinezumab (Vyepti), erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality). Zavegepant (Zavzpret) is a fast-acting CGRP antagonist you can take as a nasal spray.
Other treatment options are:
- Botox injections, which a doctor or nurse gives you about every 12 weeks
- Neuromodulators, prescription nerve stimulation devices that use magnetic waves or electric currents to modify activity in your nervous system (some of these work as abortive treatments)
Preventive treatments won’t stop all migraine attacks, but they may reduce how often you have them and how serious they are. When a migraine headache does strike, you can still use your abortive medication.
At the same time, you may be able to reduce the frequency of your migraines by:
- Identifying and avoiding any triggers you have
- Adopting a consistent sleep schedule
- Sticking to a set schedule for meals
- Exercising regularly
Using Migraine Medications Correctly
When used correctly, migraine treatments can make a world of difference. But it’s important to use them exactly as prescribed. Each comes with specific instructions on things like when it’s safe to take another dose and the maximum safe dose per day.
Most medications that work to stop migraines once they've started shouldn't be used more than about 10 days a month. Overuse can lead to rebound headaches.
Whenever you start a new treatment, be sure to learn:
- How to use it safely
- Potential side effects and interactions
- How long it may take to work
Photo Credit: Kittiphan Teerawattanakul / EyeEm / Getty Images
Global Healthy Living Foundation: “Signs Your Migraine Medication Has Stopped Working – And What To Do If It Does.”
American Headache Society: “How Migraine Evolves With Age.”
Headache: The Journal of Head and Face Pain: “Gepants,” “The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice.”
American Family Physician: “Acute Migraine Headache: Treatment Strategies.”
Nursing for Women’s Health: “Lasmiditan Is a New Option for Acute Migraine Treatment.”
UpToDate: “Acute treatment of migraine in adults.”
Neurotherapeutics: “Migraine treatment: Current Acute Medications and Their Potential Mechanisms of Action.”
Mayo Clinic: “Migraine. Diagnosis & treatment,” “Migraines: Simple steps to head off the pain.”
American Migraine Foundation: "Neuromodulation for Migraine Treatment: An Overview."