Understanding Acute Migraine Treatment
Acute migraine medications are taken the moment an attack starts, with the goal of stopping or easing symptoms - they're quite different from the daily medications used for prevention. Taking something early, while the pain is still mild, consistently leads to better results. The right choice comes down to how severe your attacks are, whether nausea is a factor, your overall health (especially any heart or stroke history), and what has or hasn't worked for you before.
Over-the-Counter Medicines for Migraine
NSAIDs: Ibuprofen and Aspirin
Ibuprofen (400-600 mg) and aspirin (600-900 mg) are the most well-supported over-the-counter options for migraine. A large 2024 real-world study of over 278,000 patients published in Neurology found that ibuprofen was rated helpful about 42% of the time -reasonable for mild to moderate attacks, though well short of what prescription options can offer. Both work best when taken at the very first sign that an attack is coming on.
Paracetamol (Acetaminophen)
Paracetamol alone is the least effective common OTC option helpful only 37% of the time in the same real-world study. It is appropriate when NSAIDs are contraindicated (stomach ulcers, kidney problems, pregnancy) but should not be a first choice when NSAIDs are tolerated.
Aspirin + Acetaminophen + Caffeine (Excedrin)
This combination helped approximately 50% of the time in the real-world data. Caffeine acts as an adjuvant, enhancing absorption of the pain relievers. A useful step up from single-agent OTCs for moderate attacks, though not suitable for caffeine-sensitive patients or frequent use.
Naproxen Sodium
Available OTC at lower doses and by prescription at higher doses, naproxen acts more slowly than ibuprofen but has a longer duration useful for attacks that build gradually or last many hours.
Prescription Medicines for Migraine
Triptans The First-Line Prescription Choice
Triptans are 5-HT1B/1D receptor agonists that constrict dilated cranial blood vessels and block pain-signalling neuropeptides. They are first-line prescription treatment in all major guidelines and rated five to six times more helpful than ibuprofen in the 2024 real-world study:
- Eletriptan rated helpful 78% of the time
- Zolmitriptan 74%
- Sumatriptan leads the pack with a 72% effectiveness rate and remains the most widely prescribed, available in more forms than any other option.
When one triptan doesn't work, it's always worth trying a different one they don't all behave the same way. Options include standard tablets, dissolving wafers, nasal sprays, and subcutaneous injections, with the injection form working fastest particularly useful during severe attacks or when vomiting makes swallowing anything impossible.
Triptans aren't suitable for everyone though. They're off the table for anyone with ischaemic heart disease, poorly controlled high blood pressure, or a history of stroke or TIA.
Antiemetics Treating Nausea and Boosting Absorption
Antiemetics play a dual role: treating nausea directly and reversing gastric stasis to improve absorption of co-administered drugs. The main options here are metoclopramide (which gets the stomach moving again and eases nausea, though only for short-term use), prochlorperazine (which tackles both nausea and migraine pain, and can also help with vertigo), and domperidone (which works in a similar way to metoclopramide). Major guidelines actually recommend taking an antiemetic alongside a painkiller or triptan even if nausea isn't much of an issue simply because it helps the other medication get absorbed properly.
Gepants A Newer Option for Triptan-Resistant Patients
Gepants are CGRP receptor antagonists a newer migraine-specific class with a different mechanism from triptans. Approved options include rimegepant (Vydura, UK and US) and ubrogepant (Ubrelvy, US). Key advantages: no cardiovascular contraindications (suitable for patients with heart disease or stroke history) and no associated risk of medication overuse headache.
Ergots
Ergots have been around longer than triptans, but they still have a place in certain situations. DHE nasal spray is rated three times more helpful than ibuprofen and may suit long-duration attacks or triptan-refractory patients. Ergots are rarely a first choice given the better tolerability of triptans and gepants.
How to Use Migraine Medicines Safely
The Medication Overuse Headache Risk
Taking any acute migraine medication more than two days per week risks medication overuse headache (MOH), also called rebound headache a cycle where frequent analgesic use sensitises the brain to pain, increasing attack frequency. If you are medicating more than twice a week, speak to a doctor about preventive treatment.
The Stepwise vs Stratified Approach
A stepwise approach starts with OTC options and escalates to triptans if they fail. A stratified approach matches medicine strength to attack severity from the outset. Most guidelines now favour stratified treatment for moderate-to-severe migraine, as it is more effective and reduces total medication use.
Conclusion
Choosing the right migraine medication really comes down to how severe your attacks are, what your body tolerates well, and your overall health history. For milder attacks, ibuprofen or aspirin taken alongside an antiemetic is a perfectly reasonable place to start. For moderate to severe attacks, triptans particularly eletriptan or sumatriptan are the most effective acute option out there. If triptans aren't an option for you, it's worth asking your doctor about gepants.
Regardless of which route you take, a few habits make a real difference in the long run taking medication early, keeping acute use to no more than two days a week, and tracking attacks in a headache diary. And if you're managing entirely on over-the-counter options but your attacks are still leaving you unable to function, talking to a doctor about prescription alternatives is genuinely the most important next step you can take.
