Drugs for Migraine
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Direct answer
Sumatriptan 50–100 mg orally at attack onset — 6 mg subcutaneously for the fastest, most reliable response, maximum 200 mg in 24 hours — aborts migraine by 5-HT1B/1D agonism: cranial vasoconstriction and inhibited release of vasoactive peptides from the trigeminovascular system. It is contraindicated in coronary disease, Prinzmetal angina, uncontrolled hypertension, hemiplegic or basilar migraine, and within 24 hours of ergotamine. Simple analgesics early in the attack — naproxen, diclofenac or paracetamol with metoclopramide 10 mg — cover mild attacks. Prophylaxis is indicated at four or more headache days a month or when attacks disable: propranolol 40–240 mg daily (topiramate 50–100 mg, amitriptyline 10–25 mg nightly, valproate with pregnancy caveats, and flunarizine 5–10 mg — the Indian prescription favourite with its weight-gain, sedation and depression profile). Analgesic use on 15 or more days, or triptan use on 10 or more days per month, for over three months defines medication-overuse headache.
What you must remember
- Acute ladder: early NSAID (naproxen 500 mg or dispersible diclofenac) with an antiemetic for mild attacks; a triptan for moderate-severe attacks; combining NSAID and triptan improves response over either alone.
- Triptan pharmacology: sumatriptan 50–100 mg PO (recurrence common, second dose allowed after 2 h if the first worked), 6 mg SC, 20 mg intranasal; chest or neck tightness after dosing is benign and vasospastic in origin — but always asked about.
- Triptan contraindications: ischaemic heart disease, previous infarction, Prinzmetal angina, uncontrolled hypertension, hemiplegic/basilar migraine, and within 24 hours of ergotamine or another triptan.
- Ergotamine 1–2 mg: the older abortive agent, now largely historical, same vascular contraindications plus pregnancy; ergotism — gangrene, vomiting — is the toxicity question.
- Prophylaxis candidates: four or more headache days monthly, disabling attacks, or overuse risk; full effect judged only after 8–12 weeks on an adequate dose.
- Prophylactic menu with discriminating adverse effects: propranolol (asthma contraindication), topiramate (weight loss, paraesthesia, nephrolithiasis, glaucoma, oral-cleft teratogenicity), amitriptyline (sedation, useful with insomnia), flunarizine 5–10 mg (depression, weight gain, parkinsonism in the elderly).
- Medication-overuse headache thresholds: simple analgesics 15+ days/month; triptans, opioids or combinations 10+ days/month, for more than three months — treatment is withdrawal of the offending drug.
- CGRP era: erenumab (monthly subcutaneous monoclonal, constipation and injection-site reactions) for prophylaxis; gepants such as ubrogepant and rimegepant as acute alternatives without vasoconstriction.
A month in a headache diary
A 28-year-old designer logs 12 headache days; four are full migraines with photophobia and vomiting, the rest mild. Step one: audit the diary for triggers and, more importantly, drug counts — she is taking a paracetamol-plus-codeine combination 12 days a month, so medication-overuse headache is already established. Step two: withdraw the combination analgesic (expect two weeks of worse headaches before improvement). Step three: build the plan — naproxen 500 mg plus metoclopramide at onset for mild attacks, sumatriptan 100 mg for severe ones, limited to under eight days a month. Step four: start prophylaxis; at her age with a low body mass index she tolerates topiramate 50 mg poorly (paraesthesia, cognitive lag), so propranolol LA 80 mg or flunarizine 10 mg nightly is the Indian-clinic alternative — with mood screening for flunarizine's depression effect.
Review at three months with the diary, not memory: fewer than four headache days means continue six months then taper; no change means recheck adherence, caffeine, sleep and the overuse count before switching drugs. The diary-driven loop — count days, cap acute drugs, titrate prophylaxis, reassess — is the structure that exam stems quietly test.
Where students slip
The triptan-contraindication stem (a 52-year-old smoker with angina given sumatriptan) is the classic wrong-drug question; candidates also mistake benign triptan chest tightness for angina and stop an effective drug. Second, the overuse thresholds — 15 days for analgesics, 10 for triptans — are the numbers to hold exactly. Third, flunarizine remains a globally odd, Indian-common drug: examinable adverse effects are depression, weight gain and parkinsonian features in the elderly. Finally, hemiplegic and basilar migraine as triptan-contraindicated (theoretical vasoconstriction risk) still appears in NBE options, alongside the 24-hour sumatriptan–ergotamine spacing rule.
Frequently asked questions
Which drug class is first choice for a moderate-to-severe migraine attack?
A triptan such as sumatriptan 50–100 mg orally at onset, or 6 mg subcutaneously for rapid relief; an NSAID with metoclopramide suits milder attacks.
Why are triptans contraindicated in coronary artery disease?
5-HT1B agonism constricts cranial and coronary vessels; in ischaemic heart disease, Prinzmetal angina or uncontrolled hypertension this risks myocardial ischaemia.
When is migraine prophylaxis started?
At four or more headache days per month, disabling attacks, or when acute medication is needed so often that overuse headache threatens; benefit is judged after 8–12 weeks.
What defines medication-overuse headache?
Simple analgesics on 15 or more days per month, or triptans/opioids/combinations on 10 or more days per month, for over three months, with headache worsening on the overused drug.
Which prophylactic is popular in Indian practice and what are its adverse effects?
Flunarizine 5–10 mg nightly — a calcium-channel blocker causing sedation, weight gain, depression, and parkinsonism in older patients.