Browse Prescribing Notes by Therapeutic Subcategory

For other pain relievers see Nonnarcotic and Narcotic analgesics sections. For antiemetics see Nausea section.
The pathophysiology of migraine headaches has not been fully defined. Therefore, the precise mechanisms of action of many antimigraine drugs remains theoretical, especially for combination products.
ANALGESICS: Aspirin, acetaminophen, and ibuprofen may be useful in treating mild to moderate migraines. These are best taken at symptom onset. Aspirin and acetaminophen are available in combination with caffeine, a cranial vasoconstrictor that potentiates analgesia. Narcotic analgesics, or opioids, can also be used for severe or refractory headaches, especially in cases where diarrhea is present.
"TRIPTANs" (eg, sumatriptan) are serotonin receptor agonists that are selective for a particular 5-hydroxytryptamine receptor subtype which mediate vasoconstriction and are present on cranial arteries, basilar artery, and in the vasculature of dura mater. Receptors on the trigeminal nerve innervating cranial blood vessels may also be affected. Side effects of the "triptans" include paresthesias, asthenia, nausea, dizziness, pain, chest or neck tightness/heaviness, and somnolence. These drugs are contraindicated in ischemic heart disease and other significant cardiovascular disease. They should be avoided within 24 hours of other "triptans" or ergot-type drugs, and during or within 2 weeks of discontinuing an MAOI.
ERGOT DERIVATIVES: Ergotamine is an α-adrenergic blocker that stimulates the smooth muscle of peripheral and cranial blood vessels. It causes depression of central vasomotor and inflammatory centers, and it antagonizes serotonin. Contraindications to the use of ergots include peripheral vascular disease, hypertension, coronary artery disease, hyperthyroidism, thrombophlebitis, impaired hepatic or renal function, sepsis, high doses of β-blockers, infection, fever, pregnancy, and nursing. Overdose can result in vasospasm and encephalopathy (ergotism); symptoms may also include vomiting, numbness, tingling, pain and cyanosis of the extremities with diminished or absent peripheral pulses, hypertension or hypotension, drowsiness, stupor, coma, convulsion and shock.
β-BLOCKERS: Propranolol and timolol are non-cardioselective β-blockers which can be used for migraine prophylaxis. The effects may take up to 3 months to be evident. β-blockers should be tapered to avoid drug withdrawal-induced headaches. Although well-tolerated, β-blockers may cause peripheral ischemia, CNS disturbances, bronchospasm, exacerbated congestive heart failure, dizziness, depression, fatigue, and reduced exercise tolerance.
OTHER CLASSES: Valproic acid is an antiepileptic agent that can be used for migraine prophylaxis. Tricyclic antidepressants (eg, amitriptyline), calcium channel blockers (eg, verapamil) and MAOIs (eg, phenelzine) are used but are not indicated for treating migraine. Butalbital is a short-acting barbiturate with anticonvulsant and sedative properties. Isometheptene is a sympathomimetic agent that constricts dilated cranial and cerebral arterioles.
ANTIEMETICS (eg, metoclopramide, prochlorperazine) may be used as adjunctive therapy. Migraines are often precipitated by delayed gastric emptying and decreased intestinal motility, and are associated with nausea and vomiting.