Medical Treatments for Headache & Migraine

Medical treatment depends on the specific headache diagnosis, attack frequency, symptom severity, other medical conditions and previous response to therapy. Treatments appropriate for migraine may not be suitable for cluster headache, tension-type headache or a secondary headache disorder.

Migraine treatment is usually divided into:

  • Acute treatment, taken during an attack to reduce pain and associated symptoms
  • Preventive treatment, taken regularly or at scheduled intervals to reduce future attack frequency, severity or disability
  • Management of contributing factors, including medication overuse and relevant medical or hormonal influences

Prescription medicines should be selected and monitored by an appropriately qualified prescriber. This page provides a general overview and should not be used as an individual treatment plan.

Acute Treatment of Migraine Attacks

Acute treatment is most effective when taken early in the headache phase of a recognised migraine attack. Options may include:

  • A triptan combined with an NSAID, such as ibuprofen or naproxen
  • A triptan combined with paracetamol
  • A triptan, NSAID, aspirin or paracetamol used alone when combination treatment is unsuitable or not preferred
  • An antiemetic for nausea or vomiting, sometimes used even when nausea is not prominent
  • Non-oral preparations when vomiting or rapid symptom progression makes tablets unreliable

If one triptan is ineffective, another triptan may still be helpful. Treatment choice must take account of cardiovascular history, other medication, pregnancy and individual contraindications.

Rimegepant, an oral CGRP-receptor antagonist, is available as an acute option for some adults when at least two triptans have not worked adequately, or when triptans are contraindicated or not tolerated and standard painkillers have been insufficient.

Opioids and ergot preparations are not routinely recommended for acute migraine treatment.

This reflects current NICE headache guidance and NICE guidance on acute rimegepant.

Preventive Treatment for Migraine

Preventive treatment may be considered when attacks are frequent, prolonged or disabling; when acute treatment is ineffective or poorly tolerated; or when medication overuse is becoming a concern.

Commonly considered oral preventive medicines include:

  • Propranolol
  • Topiramate
  • Amitriptyline

Other medicines, including candesartan, may be considered by an appropriate prescriber depending on the patient’s medical history and previous treatment response. Preventive medicines are generally introduced gradually and reviewed after an adequate trial to assess benefit and adverse effects.

Gabapentin is not recommended by NICE for migraine prevention.

Some people may benefit from riboflavin (vitamin B2), although supplements can still interact with medicines or be inappropriate in particular circumstances.

Important Topiramate Safety Information

Topiramate must not be used for migraine prevention during pregnancy. In women and girls able to become pregnant, it should only be prescribed when the requirements of the Pregnancy Prevention Programme are fulfilled. This includes effective contraception, pregnancy testing and documented discussion of the risks.

Further information is available from the MHRA topiramate safety guidance.

Medical Treatment of Cluster Headache

Cluster headache requires a different treatment approach from migraine. Because attacks become severe very quickly, ordinary oral painkillers are generally ineffective.

Acute treatment may include:

  • 100% oxygen, delivered at a flow rate of at least 12 litres per minute through a non-rebreathing mask
  • A subcutaneous or nasal triptan, selected according to clinical suitability and cardiovascular risk

For prevention during a cluster bout, verapamil may be considered. This requires medical supervision and ECG monitoring because of its potential effects on cardiac conduction.

Suspected cluster headache should be medically assessed, particularly at first presentation. Patients may require referral to a neurologist or specialist headache service to confirm the diagnosis and establish an appropriate acute and preventive treatment plan.

This reflects current NICE guidance for cluster headache.

Botulinum Toxin for Chronic Migraine

Botulinum toxin type A (BOTOX®) is an established preventive treatment for adults with chronic migraine. Chronic migraine is generally defined as headache occurring on at least 15 days per month, with migraine features on at least eight of those days, for more than three months.

NICE recommends botulinum toxin type A as an option when:

  • At least three preventive medicines have not worked, have not been tolerated or are unsuitable; and
  • Medication overuse has been appropriately managed

Treatment involves injections at multiple standardised sites around the head and neck and should be administered by a clinician trained in the recognised chronic-migraine protocol. Response is assessed by the reduction in headache and migraine days, and treatment should be discontinued if benefit is insufficient.

Botulinum toxin is intended for chronic migraine prevention, not occasional episodic migraine or the immediate treatment of an individual attack.

Further information is available in NICE guidance TA260.

CGRP-Targeted Migraine Treatments

Calcitonin gene-related peptide (CGRP) is involved in migraine pain signalling. Medicines that block CGRP or its receptor have expanded the options available for people whose migraine has not responded adequately to established preventive treatments.

CGRP Monoclonal Antibodies

Preventive monoclonal-antibody treatments include:

  • Erenumab
  • Fremanezumab
  • Galcanezumab
  • Eptinezumab

Most are administered by injection under the skin monthly or every few months. Eptinezumab is given by intravenous infusion.

Gepants

Gepants are small-molecule CGRP-receptor antagonists. UK options include:

  • Rimegepant, used for acute migraine and, in selected adults, prevention of episodic migraine
  • Atogepant, taken orally for migraine prevention

Under NICE guidance, preventive CGRP treatments are generally considered after at least three established preventive treatments have failed, have not been tolerated or are unsuitable. Continuing treatment depends on achieving a clinically meaningful reduction in migraine frequency.

These medicines are important advances, but they are not universally effective or appropriate. Selection and monitoring should be undertaken by an experienced prescriber or specialist headache service.

Medication-Overuse Headache

Frequent use of acute headache medication can increase headache frequency and contribute to medication-overuse headache.

This should be considered when, for three months or more, a person regularly uses:

  • Triptans, opioids, ergot preparations or combination painkillers on 10 or more days per month; or
  • Paracetamol, aspirin or an NSAID on 15 or more days per month

The number of treatment days matters more than the number of doses taken on each day. Keeping a headache and medication diary can help identify the pattern.

Management usually involves reducing or withdrawing the overused medication while establishing a safer acute and preventive treatment plan. Headache may temporarily worsen during withdrawal, so patients should receive appropriate clinical guidance. Opioid withdrawal or management in patients with significant comorbidity may require specialist supervision.

Patients should not change long-term prescribed medication without discussing it with the relevant prescriber.

Integrating Medical and Non-Medical Care

At The Health Equation, Gerry helps patients understand how medical treatment options may fit within a broader, personalised management plan. This may include reviewing previous treatment responses, identifying possible medication overuse and considering the contribution of sleep, breathing, hormonal, nutritional, neural and musculoskeletal factors.

Gerry does not prescribe migraine medication. Where a new prescription, medication change or specialist treatment is appropriate, recommendations can be discussed with the patient’s GP, neurologist or headache specialist. With the patient’s consent, the comprehensive consultation report can be shared directly with the relevant clinician.

Osteopathic treatment, breathing re-training and other supportive approaches are used to complement—not replace—appropriate medical care.

Book a Diagnostic Consultation

Patients seeking help with recurrent or persistent headache or migraine should book a 60-minute Diagnostic Consultation with Gerry Gajadharsingh DO.

The consultation provides time to review the diagnosis, current and previous medication, treatment effectiveness, possible adverse effects and the wider factors influencing the headache pattern. Where appropriate, the resulting written report can support further discussion with the patient’s GP, neurologist or headache specialist.

Consultations are available in Harley Street, London, and Alton Barnes, near Marlborough in Wiltshire. Patients are encouraged to send relevant medical reports, imaging and blood-test results before attending.

Continue Exploring Headache and Migraine

Our supporting pages provide further information about headache and migraine: