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Migraines are more than just headaches; they are complex neurological events that disrupt daily life. The changing treatment landscape, particularly for preventing migraines, offers patients more promising alternatives.

“I always get people to think about the non-medication options first,” says Dr Stephanie Barnes, a neurologist at Hornsby Ku-ring-gai Hospital. She says using a heat or cold pack, resting in a dark room, or extra water can help in the acute setting. She also advocates a healthy lifestyle, which includes exercise, balanced nutrition, sufficient sleep, avoiding excessive caffeine and good stress management.

However, by the time Dr Barnes sees her patients, they have usually tried these options but found that migraines still affect their quality of life.

Acute treatment for episodic migraine

The goal of acute treatment is “for the person to be headache-free within two hours,” Dr Barnes says. A secondary goal is to prevent another migraine attack for the next 48 hours.

Dr Barnes uses non-migraine-specific acute treatments such as aspirin (prescribed at 600–900 mg) and non-steroidal anti-inflammatory drugs (NSAIDs) as first line treatment. Although ibuprofen can be a useful NSAID, diclofenac and naproxen are more potent and can be more effective for treating acute migraines.

It’s also important to proactively treat nausea and vomiting to help the patient absorb other acute medications, Dr Barnes says. Anti-emetics include ondansetron, prochlorperazine, and metoclopramide. There is some evidence that intravenous metoclopramide is also effective at treating the headache component of a migraine attack.

Migraine-specific acute treatments include triptans, of which five (i.e. eletriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) are available through the Pharmaceutical Benefits Scheme (PBS). Although sumatriptan is most commonly used, it is best to try the medications sequentially if they don’t completely abort the migraine or cause problematic side effects, because another formulation may work best for the patient. However, triptan overuse (more than nine doses per month) can lead to medication overuse headache, and triptans are also contraindicated for some patients, such as those with cardiovascular disease.

“Often combination treatment ends up being the best option to have the greatest likelihood of success in getting rid of [a] particular migraine,” Dr Barnes explains.