Migraine: Acute Treatment, Prevention, and Newer Options

You feel the throbbing start behind one eye. Light hurts, sounds feel too loud, and you feel sick to your stomach. You know the next hours, or days, may be lost. Migraine is common and can be disabling, but treatment has improved a lot in recent years. This guide explains acute treatment, prevention, and the newer options, and what clinicians look at when choosing.

What migraine is

Migraine is a brain disorder that causes repeated attacks of headache, often with other symptoms [4]. A typical attack lasts 4 to 72 hours if untreated. Features often include:

• Throbbing pain, often on one side
• Moderate to severe pain that worsens with activity
• Nausea or vomiting
• Sensitivity to light and sound

About 1 in 4 people with migraine have aura. Aura is a set of nerve symptoms, often visual, such as zigzag lines or blind spots, that usually lasts 5 to 60 minutes before or during the headache.

Common triggers include stress, poor sleep, skipped meals, hormonal changes, alcohol, and changes in weather. Triggers vary from person to person.

Acute treatment: stopping an attack

First-line options

• NSAIDs, such as ibuprofen, naproxen, or acetylsalicylic acid (aspirin)
• Acetaminophen, alone or combined with other drugs
• Triptans, such as sumatriptan, rizatriptan, and zolmitriptan, which come as tablets, melt tablets, nasal sprays, and injections
• Anti-nausea medications, such as metoclopramide

Taking a triptan together with an NSAID can work better than either alone for some people [3].

Newer acute options

• Gepants, such as ubrogepant, rimegepant, and the nasal spray zavegepant, which block the CGRP pathway (calcitonin gene-related peptide, a protein involved in migraine pain)
• Lasmiditan, a ditan that acts on a different serotonin receptor

These do not narrow blood vessels the way triptans do. The American Headache Society lists them as options for people who cannot take triptans or for whom triptans did not work [1].

Medication overuse headache

Using acute medication too often can make headaches more frequent. This is called medication overuse headache. Risk rises when people use [1] [3]:

• Triptans, combination pain relievers, or opioids on 10 or more days a month
• Simple pain relievers such as acetaminophen or NSAIDs on 15 or more days a month

Opioids and butalbital-containing drugs are not recommended for routine migraine treatment [1].

What your doctor looks at

Diagnosis

Migraine is diagnosed from your history and exam. Most people do not need a brain scan. Clinicians use imaging when there are warning signs, such as a sudden severe headache, new neurological symptoms, or a big change in your usual pattern.

A headache diary helps your clinician see how many headache days you have, what you take, and how well it works.

Safety checks for triptans

Triptans narrow blood vessels slightly. Labels in Canada and the US advise against them for people with [4]:

• Coronary heart disease or a past heart attack
• Past stroke
• Uncontrolled high blood pressure
• Certain other blood vessel diseases

When to consider prevention

The American Headache Society suggests offering preventive treatment when migraine attacks are frequent or disabling, for example 4 or more headache days a month with significant disability, or 6 or more headache days a month [1]. Prevention is also considered when acute treatments do not work, are not tolerated, or are overused.

Preventive options

Older oral options include:

• Beta blockers, such as propranolol or metoprolol
• Topiramate, which can cause tingling, word-finding trouble, and birth defects
• Amitriptyline
• Venlafaxine
• Candesartan
• Divalproex, which should be avoided in pregnancy and in people who could become pregnant because of birth defect risk

Newer options target CGRP:

• Monthly or quarterly injections or infusions: erenumab, fremanezumab, galcanezumab, and eptinezumab
• Oral gepants for prevention: atogepant daily, or rimegepant every other day

For chronic migraine (15 or more headache days a month, with at least 8 having migraine features), onabotulinumtoxinA (Botox) injections every 12 weeks are another option.

The 2024 change

Earlier US guidance suggested trying several older oral drugs before CGRP treatments. In 2024, the American Headache Society updated its position to say that CGRP-targeting therapies are a first-line option for migraine prevention [2]. In practice, insurance and provincial drug plans in Canada and the US may still require you to try older drugs first.

Canada and US notes

The Canadian Headache Society also publishes guidance on acute and preventive treatment. Many of the same medications are available in both countries, though approval dates, coverage, and brand names differ.

Lifestyle steps that help

• Regular sleep and meal times
• Staying hydrated
• Regular aerobic exercise
• Limiting caffeine and alcohol
• Stress management, such as relaxation training or CBT
• Tracking triggers in a diary

Questions to ask your clinician

• Is this migraine, or could it be another type of headache?
• Which acute medication should I try first, and when should I take it?
• Am I at risk of medication overuse headache?
• Do I qualify for preventive treatment?
• Are CGRP treatments right for me, and will my plan cover them?
• Is this medication safe if I am pregnant or planning to be?
• What should I do if an attack does not respond to my usual treatment?

When to get care quickly

Call 911 or go to the emergency department if you have:

• A sudden, severe headache that peaks within a minute (thunderclap headache)
• Headache with weakness, numbness, trouble speaking, or confusion
• Headache with fever, stiff neck, or a rash
• Headache after a head injury
• Sudden vision loss

See a clinician soon if you have a new headache pattern after age 50, an aura that lasts more than an hour, or headaches that keep getting worse.

Bottom line

Migraine is a treatable brain disorder. Acute medications work best when taken early, and limiting how often you use them helps avoid medication overuse headache. If attacks are frequent or disabling, prevention can reduce how often they happen. Newer CGRP treatments now sit alongside older options as first-line choices in US guidance.

Primary AI can show you the guideline and study sources behind this topic in plain language, so you can bring better questions to your appointment.