Migraine medications

Acute and preventive medicines

• Acute medicines are taken for an attack. Their trials usually measure the result 2 hours after the dose.
• Preventive medicines are taken to reduce attacks. Daily preventive medicine does not count toward the limits below.

Rimegepant belongs to both groups: its US label covers acute treatment and prevention of episodic migraine.

A 2021 American Headache Society statement, as reported by MDedge, says to offer prevention at 6 or more headache days a month, or 3 to 4 days with some to severe disability. NICE names propranolol, topiramate or amitriptyline for prevention and advises discussing benefits and risks with each person.

Classes of acute medicine

Class	Pages	Days per month, for more than 3 months	ICHD-3
Triptans	sumatriptan, rizatriptan, zolmitriptan, eletriptan	10 or more	8.2.2
Non-opioid painkillers	ibuprofen, naproxen, acetaminophen, aspirin	15 or more	8.2.3
Combination painkillers	Excedrin	10 or more	8.2.5
Ergotamines	Not covered here	10 or more	8.2.1
Opioids	Not covered here	10 or more	8.2.4
Gepants	rimegepant, ubrogepant	Not named; general rule 10 or more	8.2.8
Ditans	lasmiditan	Not named; general rule 10 or more	8.2.8

What guidelines name

Guidelines are written for prescribers. The choice depends on the person and is made with a doctor or pharmacist.

• NICE CG150 (UK). An oral triptan with an NSAID or with paracetamol. For people who prefer one medicine: an oral triptan, an NSAID, aspirin or paracetamol. An anti-emetic may be added. NICE says not to offer ergots or opioids for acute treatment, and not to offer aspirin to under-16s.
• American Headache Society, 2021, as reported by MDedge. NSAIDs, non-opioid painkillers, acetaminophen or caffeine-containing combinations for mild to moderate attacks. Triptans, gepants or ditans for moderate or severe attacks. A non-oral form when attacks often bring severe nausea or vomiting.

Monthly limits

ICHD-3 limits count days, not doses, and apply when overuse lasts more than 3 months with headache on 15 or more days a month. All non-opioid painkillers count as one class. Several types, none over its own limit, count against 10 days in total. Other acute medicines fall under the general subtype 8.2.8, at 10 or more days a month for more than 3 months. It does not name gepants or lasmiditan.

Some US labels use 10 days where ICHD-3 uses 15. The ibuprofen migraine label warns about use on 10 or more days a month.

One month over a limit is not a diagnosis. See medication-overuse headache for the criteria and the position on gepants and lasmiditan, and use the medication days counter for your own count.

Recording a medicine

Write down the day, time, medicine and form, then the pain 2 hours later. Trials report two outcomes: no pain at all, and pain reduced to mild or none. A printable diary has a column for this.