Acute migraine medications and my journey to find relief

This is not a paid post and I am not affiliated with any pharmaceutical company. The reason I decided to write a series of posts about migraine medications is that there are so many types and groups. It can be very confusing to navigate the options. This post details some of the most commonly used migraine medications to treat acute migraine attacks. I only review the groups of medications that I personally tried and share my personal experience with those groups. You should consult your physician about which group and specific medication are right for you.

Acute migraine medications can be grouped into several categories:

• CGRP antagonists (gepants)
• Analgesics
• Triptans
• Ergotamines

There are other groups of medications for acute treatment such as corticosteroids, but I won’t be reviewing them in this post as I don’t have 1^st hand experience with them.

Let’s review each main category for how it works, the medications that fall into that category, and my experience with them.

CGRP Antagonists (gepants)

A little background

CGRP inhibitors are a newer class of migraine medications that are used to treat and prevent migraines. Here, I focus only on CGRP receptor antagonists (gepants) that are used for acute migraine treatment. I am starting my post with this group of meds, because I found it to be most effective in the treatment of acute migraines in 35 years of my migraine journey.

Gepants are designed to specifically block the CGRP (calcitonin gene-related peptide) protein. This protein is believed to play a significant role in the development of migraine pain and inflammation during a migraine attack.

CGRP levels are higher during the migraine attack. These proteins are bombarding the sensory nerve endings causing migraine symptoms we are all too familiar with! CGRP antagonists block these proteins from attaching to the nerve endings, thus relieving pain, light & sound sensitivity, and nausea.

Which medications fall into this group?

• Ubrelvy (ubrogepant): Approved Dec 23, 2019
• Nurtec ODT (rimegepant sulfate): Approved Feb 27, 2020.
• Qulipta (atogepant):  Approved Sept 28, 2021

My experience with CGRP antagonists migraine medications

From the group of medications listed above, I have tried Ubrelvy to treat my acute migraines. I started my Ubrelvy journey in the early summer of 2021. My overall experience with it has been very positive and I found the drug to be effective.

Here is a short summary of my experience:

• I take 50mg pill and it usually works within 2 hours. It takes care of the pain and all the migraine symptoms.
• Convenient packets that are easy to open. If you have ever tried to open some tricky med packages while in migraine agony, you will appreciate how easy this one is to open!
• Unlike other medications, it doesn’t make me feel tired or lethargic. Also, it doesn’t give me any cardiovascular or respiratory side effects.
• The second dose can be taken within 2 hours if the first one didn’t help. I only had to do it a couple of times though. In 1.5 years of taking Ubrelvy, one dose reliably helps me most of the time.
• I take it no more than 8 days a month.

You can find my detailed experience with Ubrelvy in this recent post. After suffering from migraines for 35 years, I believe I found a good solution for my chronic migraines. Since I experience migraine almost every day, this medication with at least a third to a half of my acute attacks per month. I also take fewer triptans as a result of me trying Ubrelvy.

I am hugely transparent in my posts and want to underscore that I am not affiliated in any way with the makers of these drugs. I also want to bring attention to the fact that gepants belong to a group of medications that are called small molecules, which means they rapidly penetrate the brain and work quickly. However, they are processed out by your liver and could cause potential liver damage, especially if you have other underlying health conditions. I don’t have any liver conditions, but my doctor periodically checks my liver counts via a quick blood test. So far, I have been taking Ubrelvy for about 1.5 years and had 3 blood tests that were all normal. 

Analgesics

A little background

Analgesics are commonly used for mild to moderate migraines. They are considered non-specific migraine medications because they work on pain systems in general and were not specifically designed to treat an acute migraine attack. Many patients respond well to this simple treatment option.

Which medications fall into this group?

The most common medications in this group are:

• Aspirin
• Acetaminophen (Tylenol)
• Non-steroidal anti-inflammatory drugs (NSAIDs). For example, the over-the-counter (OTC) groups include ibuprofen also known under brands such as Advil, Motrin and naproxen also known under brand such as Aleve. There are also NSAIDs that must be prescribed by your doctor. For example, higher dosage of flurbiprofen, diclofenac potassium and indomethacin.

There are also combination analgesics that combine a primary analgesic like the ones mentioned above with other medications. For example:

• Excedrin Migraine has acetaminophen, aspirin, and caffeine.
• Fioricet contains acetaminophen, caffeine, and butalbital. Butalbital is a serious medication, belonging to a class of barbiturates. They are central nervous system depressants and are often used in combination with analgesics to relieve pain. These medications like Fioricet are not OTC and will only be prescribed by your physician as they have habit-forming risks.

My experience with analgesics:

1. I have tried all of the medications listed above. Most of them were used early on in my migraine journey when migraine-specific medications were not yet available. Simple analgesics such as acetaminophen, NSAIDs, and aspirin don’t relieve my migraines as my case is pretty severe.
2. A special note of caution about simple analgesics: many analgesics have side effects such as upset stomach, stomach, and intestinal ulcers if overused or used more than directed. I definitely experienced heartburn and an upset stomach from those. Acetaminophen can also cause liver damage if not used as directed.
3. At one point, my doctor prescribed Fioricet for me. I noticed that the pain relief was moderate. However, butalbital, one of the drugs in Fioricet, made me feel very strange. I felt sedated and yet also intoxicated. I did like the moderate pain relief that it brought, but it would wear out in a few hours and my migraine was back with vengeance. Due to its habit-forming risks, not complete migraine relief, and also the risk of medication overuse headaches (my attacks are frequent), I decided, it was not the medication for me. It might work better for those with intense but infrequent migraine who don’t have side effects from this drug.
4. At times, if my migraine is very mild, I will use Excedrin migraine or take Tylenol and drink a cup of coffee. I do feel some relief from migraine pain with caffeine.
5. Since the invention of newer groups of medications that were specifically designed for acute migraine treatment, such as triptans or CGRPs, I hardly ever use this group of meds for migraine relief.

Triptans

A little background

Triptans, such as sumatriptan, rizatriptan, and zolmitriptan, are a class of drugs that target serotonin receptors in the brain and are more effective for moderate-to-severe migraines. One of the simplest and easy-to-follow explanations about triptans that I found was from WebMD: Triptan drugs work like a brain chemical called serotonin. This helps quiet down overactive pain nerves. In other words, triptans reverse the changes in your brain that caused your migraine.

Which medications fall into this group?

There are a lot of triptan medications. The list below lists some of the most commonly used ones.

• Almotriptan (Axert)
• Eletriptan (Relpax)
• Frovatriptan (Frova)
• Lasmiditan (Reyvow)
• Naratriptan (Amerge)
• Rizatriptan (Maxalt)
• Sumatriptan (Imitrex, Onzetra Xsail, Sumavel DosePro, Zembrace)
• Zolmitriptan (Zomig)

That is a long list! What are the differences?

One of the differences is the form that these acute migraine medications come in. Some of these come in several forms such as the swallowable pill, dissolvable pill, nasal spray, and/or injection form. Others come only in pill or only in injection form. You should discuss with your doctor which form is best for your type of migraine. Nasal spray, for example, may work great when migraine sufferers have such severe nausea and vomiting that they cannot take a pill.

Another difference is how long these medications work in your system. For example, frovatriptan takes longer to start working, but will stay in your system longer than other triptans. Naratriptan lasts the second longest of all triptans but might work a bit faster than frovatriptan. Sumatriptan, zolmitriptan, and rizatriptan are among the fastest to start working (rizatriptan starts working within about 30 min). However, they have a very short elimination half-life time of only 2-2.5 hours compared to frovatriptan 26 hours. So, if your migraine lasts more than 4 hours, they may not be best for you.  

My experience with triptan migraine medications:

Pills:

I have been taking triptanes for acute migraines almost 22 years now. My first experience was with sumatriptan (Imitrex) and Zolmitriptan (Zomig). Neither one worked well for me because my migraine attacks lasted more than a day. But these medications stop working within about a few hours. So, my migraines would return and I ended up in a rebound headache cycle that was impossible to manage.

Then in 2002, Relpax was launched in the USA. The clinical trials showed that it was clinically more effective than Imitrex and also relieved light sensitivity and nausea. For example, one meta-analysis found that eletriptan was more likely to lead to a pain-free response compared to other triptans (measured after 2 hours and 24 hours). After trying Relpax, I felt an immediate improvement in managing my acute migraines.

While it varies for every patient, Relpax (eletriptan) worked very reliably for me for a long time. It took care of migraine headache pain within 1-2 hours and allowed me to get back to some of my daily activities, even if on a limited basis.

It does come with some nuanced side effects that I tolerated while getting the benefit of pain relief. I experienced a stiff neck, sore breasts, tiredness, aching joints, heavy chest feeling, and sensitivity to hot drinks/water. It was not ideal, but since no other medication was working well for me and CGRP was not yet in existence, I managed migraines predominantly with this acute migraine med. If you can afford to sleep for 20-30 min when this med starts working, it does wonders in terms of curbing side effects like tiredness and fatigue.

Nasal spray:

I tried the nasal spray form of sumatriptan before I took Relpax. It was hard to dose due to the nasal spray being a bit messy and harder to administer. It was also very unpleasant because some of the medication ran down my throat and I had a very bitter taste for hours after taking it. The benefit was that the nasal spray kicked in faster since it went straight into the bloodstream and didn’t have to be digested.

Injections:

I only had triptan injections done in ER for me a few times when my migraines were still unmanageable and I have not yet found the right mix of acute and preventative measures. It has been a long time since I had to have a triptan injection of any kind. It can be very helpful though if the migraine is severe or you can not take a pill or tolerate nasal spray.

Ergotamines

A little background

Ergotamines are a group of medications that are used to treat moderate-to-severe migraines and persistent, hard-to-treat migraines. They work similarly to triptans in that they are a vasoconstrictor type of medication. What does that mean? During migraines, certain blood vessels are widened which creates that throbbing headache. Erotamines work by binding to certain serotonin receptors thus constricting the vessels. That can help the pain and inflammatory response that happens during an acute migraine attack.

Studies^1-3 show that ergotamines (aka ergots) are less effective than triptans in treating acute migraines. However, they are very helpful for migraine sufferers who failed triptans or have a persistent migraine that is hard to treat.

Which medications fall into this group?

• Migranal® (dihydroergotamine mesylate) nasal spray
• H.E. 45® (dihydroergotamine mesylate) injection
• Cafergot® (ergotamine and caffeine) tablets
• Ergomar® (ergotamine tartrate) dissolving tablets
• Migergot® (ergotamine tartrate and caffeine) suppository
• Trudhesa™ (dihydroergotamine mesylate) nasal spray

My experience with ergotamine group of migraine medications

I had a direct experience with Migranal nasal spray and D.H.E 45 injection.

My experience with Migranal nasal spray:

Pros:

1. It did relieve my headache and started working relatively quickly since it is a nasal spray.
2. The spray was easy enough to administer for me. If any of you have ever experienced tough-to-open packaging when you are in migraine pain agony, you will know what I mean. I jokingly call those “adult-proof” packages. The Migranal package directs you to do 4 test sprays in the air, then 1 in each nostril. After that, you wait for 15 minutes and do 1 more spray in each nostril.
3. It is non-oral so if you are very nauseated or vomiting, this may be a method to consider.

Cons:

1. It was messy. The spray would run out of my nose and it felt like more than half a dose came right out. The instructions implicitly say not to tilt your head or breathe in through your nostrils hard right after the spray.
2. It was hard to dose and didn’t work consistently. Because so much medicine run out after both sprays that are allowed, my migraine didn’t improve. As a result, I could not take other rescue medications like triptans since they have a known interaction with ergots and can not be taken at the same time. Which for me meant, enduring moderate-to-severe pain for 24 hours at which point it was ok for me to attempt treating the migraine with a triptan again.
3. The taste was very bitter. Some of the medication managed to get into my throat and I had a bitter taste for hours afterward. Not the best experience when you are already nauseated from a migraine. But I was willing to endure it for pain relief when it worked.

Overall, my experience with Migranal was very mixed and the effectiveness was suboptimal. My doctor and I decided I should try the D.H.E. 45 injection instead.

My experience with D.H.E. 45 Injection:

Unfortunately for me, the injection of D.H.E. 45 gave me heart and breathing issues. My heart was beating fast. I felt such dizziness and tightness in my chest that I was barely able to get through it without an ER visit due to side effects. I called my doctor’s office to share what happened. After that, I had to stop any use of this migraine medication.

Summary:

You can see from my experience, I had good results with gepants and triptans. But everyone’s experience with migraine is so different! Your migraines could be less severe than mine and the most basic over-the-counter medications could just be enough. Or you may need every ammunition to beat this debilitating condition! Sharing my experience in this blog is my way of saving someone searching for answers time while providing them with quality information. Which acute medications worked best for you and for what type of migraine? Please, share in the comments below.

References:

1. Schwedt T, Garza I. Acute treatment of migraine in adults. UpToDate. Available at https://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults#H3489319. Accessed 10/9/2021.
2. Acute Migraine Headache: Treatment Strategies. American Family Physician. Available at https://www.aafp.org/afp/2018/0215/p243.html. Accessed 10/9/2021.
3. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Ergot Alkaloids. [Updated 2018 Feb 10]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK548405/. Accessed 10/9/21.