Medication for Migraine: Fact sheet from The Migraine Trust

Fact sheet

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Medication for Migraine

This fact sheet is a general guideline about the types of medication in the treatment of migraine. This is one of a range of fact sheets written and researched by The Migraine Trust to help you understand and manage your condition.

There are a huge range of drugs available to treat migraine. It is useful to have some background information to help you make informed choices about which drug may be best for you.
There is no standard treatment for migraine, so the choice of drugs should always be made on an individual basis.
Whilst drugs may be necessary to treat your attack, an important factor in the overall management of migraine is finding out what may be causing it and other ways you can manage it.

How drugs work
Most drugs act in one of the following ways:
• replacing substances in the body which you lack
• destroying organisms such as bacteria which have invaded the body
• changing the way cells function.
The drugs used in migraine mostly fall into the last category.
Understanding how drugs are classified
Drugs are classified in the following way:
• the group name: according to their chemical similarity, their use or the way they work
• the generic name: the name of the basic active ingredient e.g. aspirin
• the brand name: the name chosen by the manufacturer e.g. Anadin.
It is useful to be able to identify drugs by their generic names, especially with Over-The-Counter (OTC) preparations, (as opposed to a Prescription-Only-Medicine (POM). This will give you a clearer idea of what you are choosing.
Different drug companies produce aspirin (for example) under different brand names. By knowing the generic name you may be able to:
• select a cheaper drug which is just as effective for you
• stop you duplicating and taking more than one preparation with the same active ingredient
• save money which is useful if you are coping with a long-term condition.
Brand names differ from country to country, but the generic name is usually the same (except in the USA), however this is currently under review.

Finding the right migraine drug for you

There are two groups of drugs for treating migraine:
• acute - treatment when the migraine starts
• prophylactic - treatment to prevent an attack.
For more details see: The Migraine Trust Medication for Migraine Tables. This gives more information about the specific drugs available for the treatment of migraine.

Prophylactic
In the past few years the use of prophylactic drug treatments has fallen. This could be because some prophylactics have side effects such as weight gain and can take time before they start to show a beneficial effect. Also acute medication has improved for migraine. However, if you are having at least 4 migraine attacks per month you may wish to discuss prophylactic medication with your GP.
It could take up to three months for the preventative effect of the drug to be felt. Therefore, if the drug did not relieve your migraine attack it does not mean that the drug itself did not work but that you need to give it some time.
It is important to note that some preventative drugs prescribed by your GP for your migraine may be licensed for other conditions such as high blood pressure, depression or epilepsy. This could mean that the information sheet is more relevant to those conditions. If you see information in the Patient Information Sheet which you don’t understand you should discuss this further with your GP.

Acute
Over the years there have been positive developments in acute medication for migraine. These treatments can’t stop you from getting migraine but they can reduce your pain and other symptoms.
Drugs called triptans have been designed especially for migraine attacks. Their main effect is to reduce pain information coming to the brain.
Before taking any drug treatment
It is always important to read the patient information sheet supplied with the drug. This is important for a number of reasons:
• some drugs cannot be taken if you have other medical conditions or are taking certain medications
• some drugs can cause side effects which, although mild, are worth knowing about so you can inform your GP if you experience them
• some drugs interact with other drugs or foods or alcohol. This interaction can increase the drug’s effectiveness. Caffeine for example is sometimes added to improve the effectiveness of pain relief. Some interactions can be harmful and can reduce the efficiency of the drug. Some herbal
• remedies can also interact in this way so it is important to inform your GP of everything you are taking to help your migraine.

The combination of drugs
To get the best out of your medication you should always aim to take the right drug, in the right amounts, at the right time.
There is now substantial evidence that you need to take your medicine at the first sign of an attack, as soon as you start having symptoms.
The combination and method by which drugs are taken can make a difference to the time it takes for them to be absorbed into your system and to produce an effect. For example, analgesics (pain killers) taken in soluble form are absorbed more quickly. This can be a crucial factor in migraine, because when an attack takes hold the digestive system slows down. This could mean that drugs taken at the wrong time may not be properly absorbed and so will not be as effective.

Taking drugs
Some people with migraine experience vomiting and find it difficult to take medication by mouth. There are various ways that drugs can be taken, including:
• being swallowed
• held under the tongue
• held between teeth and cheek
• inhaled
• taken via the rectum (back passage) through suppositories
• by injection
• through the skin in patches.

Taking control
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By keeping a record about all aspects of your migraine you be able to find out what works best for you. This may be a change in your lifestyle
and / or the use of drugs. It is helpful to keep a record on as many aspects of your daily life as possible to see what may be a factor in triggering a migraine attack. This could include what and when you eat, exercise and patterns of sleep. Using this information combined with a record of the severity of the migraines you should be able to understand
what may cause your migraine, the signals to look out for, what drugs work for you and when is the best time to take them.

(The Migraine Trust also produces a sample migraine attack record and migraine diary.
This can be photocopied or printed from our web site: www.migrainetrust.org or you can request a copy from our Support Services).

Keeping a record of the drugs you are taking
With any drug treatment you should keep a record of the drugs you are taking. This will give you an idea about the type of drugs that work best for you. You should keep a record of the following:
• generic name
• date started
• date finished
• daily dosage taken
• effectiveness
• side effects (if any)
• comments
You should also include any vitamins, herbal products, tonics or supplements, inhalers, creams or ointments that you are using.

(The Migraine Trust also produces a sample drugs record in fact sheet 5a . This can be photocopied or printed from our web site: www.migrainetrust.org or you can request a copy from our Information Services.

Medication Overuse headache
Medication Overuse headache is one of a group of headaches that come under the umbrella term of
Chronic daily headache (CDH).

A useful definition of CDH is when you have a headache for more than four hours on more than 15 days per month. Some people experience these headaches for a period of six months or longer.
Causes
Chronic daily headache is associated with:
• head injury
• a previous history of migraine
• overuse of painkilling medications.
• obesity
• stressful life events
• being female

Medication Overuse Headache (MOH)
For many people, painkillers are a safe and effective way of treating headache or other pain.
If you have regular migraine you will most likely experience an attack once or twice a month. Sometimes an additional less severe headache may develop or the migraine attacks may become more frequent.
The pain and discomfort you are feeling every day means that you will be increasing your dosage of painkilling medications due to the development of tolerance (when your body becomes used to the drug so it stops being as effective.) This can then lead you into a process where the drugs are actually making your headaches worse and more frequent. This process is called ‘rebound phenomenon’.

Migraine or Medication Overuse Headache?
It is characteristic of migraine that people have episodic attacks of multiple symptoms (pain, nausea, vomiting, sensitivity to light and sound) but they go back to their usual state of health in between attacks. Medication overuse headache, in contrast, is a dull constant headache which is often worse in the morning. It is present on most days or part of every day. It is possible to have medication headaches most days with episodic migraine pain superimposed on the ‘headache ‘.
‘Rebound phenomenon’
Only people who are prone to headaches develop this syndrome, generally those with migraine or a family history of migraine. It is generally not seen in people taking painkillers for reasons other than headaches, such as arthritis or back pain.
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It is a vicious cycle and even if the medication is stopped, withdrawal symptoms are commonly
And you should only withdraw acute medications under medical supervision. This can help exclude any other underlying causes of the headache and help if you need to start taking a headache preventative medication as soon as you have withdrawn from your acute medication.
reported including chronic headache. The need to alleviate these withdrawal symptoms perpetuates further use of painkilling drugs and can result in a cycle of medication overuse.

Drugs and pregnancy
Drugs involved in the development of medication overuse headache
You should be very cautious about taking drugs while pregnant or breast-feeding. Fortunately, many women’s migraine attacks improve in pregnancy, especially after the first three months. You should seek medical advice if you are pregnant whilst taking any medication.
Drugs that are associated with the development of chronic daily headaches include: Caffeine, Ergots, Paracetamol, Codeine and the Triptans. (See tables 1 and 2 for more details).
Further problems

Children and over 65s
The overuse of acute migraine drugs can also stop preventative migraine medications from working and long-term use of acute drugs may be damaging to the liver and kidneys.
Very little scientific evidence has been gathered from children and those who are over 65 with migraine. This may mean that a drug normally prescribed for migraine may not be licensed for use with this group of people. Therefore, a child or person over 65 maybe prescribed a drug from the GP on a ‘named patient ‘basis. This means that the GP will follow a set of guidelines when prescribing the drug. The GP will make a decision as to the appropriateness of the medication for the individual patient based on medical evidence. As the patient information leaflet does not apply to these groups it is important to raise any questions or issues. The GP should give a clear account of any risks and benefits. If there is any thing you don’t understand you should always discuss this further with your GP.

The treatment
The only way of treating this condition is to stop the medication. The withdrawal process is very individualised, based on the types of drugs you are taking. Some people will stop the drugs immediately, others may taper them and others may even need to be hospitalised for detoxification under medical supervision.
It is vital that you seek medical advice when changing your medication in any way

CAUTION
Drugs and new treatments for migraine are changing all the time. If you are on long term medication you should ensure that your treatment is regularly reviewed by your doctor.

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References Used:
• Silberstein, SD Lipton, RB Goadsby, PJ Smith, RT. Headache in Primary Care. Oxford: Isis Medical Media, 1999.
• Dowson, A.J. Migraine and Other Headaches Your Questions Answered. Edinburgh: Churchill
• Fontebasso, Manuella Migraine and Other Headaches, Answers at Your Fingertips Class Publishing, 2007
• The Migraine Trust, Hot Topics in Headache: London: 2002
• The Migraine Trust Web Site: www.migrainetrust.org

Useful Contacts:
Brain and Spine Foundation
Pain Concern
7 Winchester House
PO Box 13256
Cranmer Road
Haddington EH41 4YD
Kennington Park
London SW9 6EJ
Helpline: 0808 808 1000
Tel: 01620 822572

Website: www.brainandspine.org.uk

The Migraine Trust website: www.migrainetrust.org

OUCH UK (for Cluster Headaches)
World Headache Alliance
Pyramid House
Email: mail@w-h-a.org
956 High Road
Website: www.w-h-a.org
London
N12 9RX
Email: info@ouchuk.org

24 hour help line : 01646 651 979
Website: www.ouchuk.org
This fact sheet is available in larger print on request.
This fact sheet was produced by the Education Department at The Migraine Trust. The information in this fact sheet has been read and checked for accuracy and relevance by headache professionals and people living with migraine. Date reviewed February 2009
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The Migraine Trust, 55 – 56 Russell Square, London, WC1B 4HP
Tele: 020 7436 1336 Fax: 020 7436 2880 Email: info@migrainetrust.org
Website: www.migrainetrust.org . Registered Charity No: 1081300. 6